Khyber Pakhtunkhwa Health Sector Strategy 2010 2017healthkp.gov.pk/public/uploads/downloads-42.pdf · BHU Basic Health Unit BISP Benazir Income Support Programme ... MO Medical Officer

Khyber Pakhtunkhwa Health Sector

Strategy 2010 – 2017

December 2010

i

Table of contents

Abbreviations .................................................................................................................................. iii

Introduction 1

Rationale 1

Goal and priority outcomes ...................................................................................................... 2

Implementation: key considerations ........................................................................................ 3

The Strategy document ........................................................................................................... 5

Part 1. Challenges for each health outcome area ........................................................................ 0

Outcome1: Enhancing coverage and access to essential health services especially for the poor and vulnerable .................................................................................. 0

Outcome 2: A measurable reduction in morbidity and morbidity due to common diseases especially among vulnerable segments of the population. ................... 4

Outcome 3: Improved human resource management ........................................................... 13

Outcome 4: Improved governance and accountability .......................................................... 16

Outcome 5: Improved regulation and quality assurance ....................................................... 19

Part 2. Key objectives and strategies for each health outcome.................................................. 21

Part 3. Performance indicators ................................................................................................... 39

Part 4. Health expenditure .......................................................................................................... 51

Health financing and expenditure .......................................................................................... 51

Part 5. Funding implications ....................................................................................................... 59

Costing of priority health measures ....................................................................................... 59

Funding of priority health measures ...................................................................................... 63

Part 6. Implementation, monitoring and evaluation mechanisms ............................................... 65

Implementation ...................................................................................................................... 65

Monitoring and evaluation ...................................................................................................... 65

Next steps 67

Annex 1: Stakeholder consultation ............................................................................................... 68

Strategy development; the process ....................................................................................... 68

List of consulted stakeholders ............................................................................................... 71

List of tables

Table 1 Nominal recurrent expenditure (Rs. millions) by the District Governments on

Health, funded by the Government of Khyber Pakhtunkhwa FY 2005/06 to

2009/10 ........................................................................................................................... 53

Khyber Pakhtunkhwa Health Sector Strategy Draft

ii

Table 2 Nominal Expenditure (Rs. millions) by the DoH, funded by the Government of

Khyber Pakhtunkhwa FY 2005/06 to 2009/10 ................................................................ 54

Table 3 Real adjusted Expenditure (Rs. millions) by the DoH, funded by the Government

of Khyber Pakhtunkhwa FY 2005/06 to 2009/10 ............................................................ 55

Table 4 Combined expenditure (Rs. millions) in health sector of Khyber Pakhtunkhwa in

2007/08 and 2008/09 ...................................................................................................... 56

Table 5 Costing of Priority Health Measures (Rs. millions) in health sector of Khyber

Pakhtunkhwa FY 2010/11 to 2016/17 in Rs. millions...................................................... 59

Table 6 Funding of Priority Health Measures (Rs. millions) in health sector of Khyber

Pakhtunkhwa FY 2010/11 to 2016/17 in Rs. millions...................................................... 64

List of figures

Figure 1 Provincial health allocation vs. expenditure FY 2005/06 -2009/10 ................................ 57

Figure 2 District health allocation vs. expenditure FY 2005/06 -20009/10 .................................. 57

Figure 3 District health expenditure per capita 2009/10 .............................................................. 58

Abbreviations

iii

Abbreviations

ADP Annual Development Programme

ARI Acute Respiratory Infection

BHU Basic Health Unit

BISP Benazir Income Support Programme

BoD Burden of Disease

CESSD Communication for Effective Social Services Delivery

CDS Comprehensive Development Strategy

CIET Community Information Empowerment & Training

CMW Community Midwife

CPSP College of Physicians and Surgeons Pakistan

DAD Donor Assistance Database

DALYs Disability Adjusted Life Years

DHDCs Divisional Health Development Centres

DHIS District Health Information System

DHOs District Health Officers

DHQ District Headquarter hospitals

DoH Health Department

EDO-H Executive District Officer of Health

EmOC Emergency Obstetric Care

EPI Expanded Programme on Immunisation

FATA Federally Administered Tribal Areas

FLCFs First Level Care Facilities

FY Financial Year

GIS Geographical Information System

GDP Gross Domestic Product

GoP Government of Pakistan


iv

HMIS Health Management Information Systems

HSRU Health Sector Reform Unit

IDPs Internally Displaced Persons

IQHCS Improving Quality of Health Care Services

IRNUM Institute of Radiotherapy and Nuclear Medicine

KMU Khyber Medical University

LHV Lady Health Visitor

LHW Lady Health Worker

LRH Lady Reading Hospital

MBBS Bachelor of Medicine and Bachelor of Surgery

MCC Medicine Coordination Cell

MCH Mother and Child Health

MDGs Millennium Development Goals

MICS Multi-Indicator Cluster Survey

MMR Maternal Mortality Ratio

MNCH Maternal Neo-natal and Child Health

MO Medical Officer

MRC Medical Rehabilitation Centre

MS Medical Superintendent

MTBF Medium Term Budgetary Framework

MTDF Medium Term Development Framework

NACP National AIDS Control Programme

NFC National Finance Commission

NGO Non Government Organisation

NHP National Health Policy

NIPS National Institute of Population Studies

NP FP&PHC National Programme for Family Planning and Primary Health

Care

Abbreviations

v

NTP National Tuberculosis Programme

NWFP North Western Frontier Province (previous name for Khyber

Pakhtunkhwa)

OOP Out of pocket

OPD Outpatient department

OSCE Objective Structured Clinical Examination

PAC Public Accounts Committee

PAEC Pakistan Atomic Energy Commission

PBM Pakistan Bait-ul-Maal

PCNA Post Crisis Needs Assessment

PDHS Pakistan Demographic and Health Survey

PHDC Provincial Human Development Centres

PHSA Provincial Health Services Academy

PIDE Pakistan Institute of Development Economics

PIFRA Project to Improve Financial Reporting and Auditing

PIPOS Pakistan Institute of Prosthetic and Orthotic Sciences

PGMI Post Graduate Medical Institute

PM&DC Pakistan Medical and Dental Council

PNC Pakistan Nursing Council

PPHI People’s Primary Healthcare Initiative

PRSP II Poverty Reduction Strategy Paper II

PSLM Pakistan Social and Living Standards Measurement

RHC Rural Health Centre

Rs. Rupees

SECP Security and Exchange Commission of Pakistan

TB Tuberculosis

TB DOTS Tuberculosis Directly Observed Treatment Short Course

THQ Tehsil Headquarter Hospital


vi

UNFPA United Nations Population Fund

UNICEF United Nations Children’s Fund

WAPDA Water and Power Development Authority

WB World Bank

WHO World Health Organisation

WMO Women Medical Officer

vii

Introduction

1

Introduction

Context

After seven years of conflict and insecurity inhibiting economic growth and social

progress, the government of Khyber Pakhtunkhwa has developed a

Comprehensive Development Strategy (CDS) with a vision of ‘attaining a

secure, just and prosperous society through socio-economic and human

resource development, creation of equal opportunities, good governance and

optimal utilisation of resources in a sustainable manner.1 The CDS outlines

goals, strategies and priority programmes for all sectors. To ensure coherent

implementation, the priority programmes are budgeted within a newly introduced

Medium Term Budgetary Framework (MTBF).

This strategy for the health sector2 is based on the strategic directions and

priorities of the CDS and has been developed by the government in consultation

with stakeholders. The strategy incorporates priorities reflected in; the draft

National Health Policy (2010), national policies designed to achieve the health

related MDG targets of 2015, the Medium Term Development Framework

(MTDF), Post Crisis Need Assessment (PCNA) and the Poverty Reduction

Strategy Paper (PRSP-II).

The cost estimates of the CDS anticipate that health will receive, on average,

11% of available domestic financing.3

Rationale

Health systems should improve the health status of individuals, families and

communities, defend the population against what threatens its health; protect

people against the financial consequences of ill-health; provide equitable access

to people-centred care and make it possible for people to participate in decisions

1 As expressed in the government of Khyber Pakhunkhwa ‘Comprehensive Development

Strategy 2010-2017’, April 2010

2 Hereafter referred to as ‘the strategy’

3 CDS


2

affecting their health and health system.4 In Khyber Pakhtunkhwa, as in other

parts of the country, the quality of health services is often poor, resulting in a

waste of both government and household resources and leading to a low impact

on health outcomes.

Goal and priority outcomes

The goal of the Health Department (DoH), to be accomplished in partnership

with stakeholders is ‘to improve the health status of the population in the

province through ensuring access to a high quality, responsive healthcare

delivery system which provides acceptable and affordable services in an

equitable manner.5 This includes achieving the targets set for the MDGs (2015).

The priority areas for health from the CDS have been formulated into five health

outcomes, budgeted in the MTBF. These are:

Outcome 1: Enhancing coverage and access to essential health services

especially for the poor and vulnerable.

Outcome 2: A measurable reduction in morbidity and morbidity due to common

diseases especially among vulnerable segments of the population.

Outcome 3: Improved human resource management.

Outcome 4: Improved governance and accountability.

Outcome 5: Improved regulation and quality assurance.

While objectives have been determined for each of the strategies, the following

indicators will be tracked for monitoring the success (or otherwise) of the

strategy overall.

Indicator

Infant Mortality Rate (IMR) per 1,000 live births – MDG 4

Proportion of fully immunised children – MDG 4

Maternal Mortality Ratio (MMR) per 100,000 live births – MDG 5

4 World Health Organisation

5 CDS

Introduction

3

Contraceptive Prevalence Rate (CPR) – MDG 6

% of public healthcare institutions meeting 75% of quality standards

% population having access to the Minimum Health Service Package (MHSP) for primary and

secondary healthcare services.

% population having access to preventive services/education.

Government Expenditure on health per capita.

% of staff of health department meeting the skills requirements of their position.

Policy, resource allocation and flow of funds demonstrably match the needs of target

populations ascertained by the DHIS and other programme MISs.

No of analytical /monitoring and evaluation (M&E) reports generated by the Health

Department.

Implementation: key considerations

The implementation of this strategy will contribute to provincial governance

reforms, peace building and the long term reform agenda of the health sector

through addressing health systems weaknesses and an enabling environment.

Implementation will improve the quality of health services through increasing

resources (financial, human, material), strengthening monitoring, supervision

and regulatory roles at facility, district and provincial levels; regulating quality

and availability of private health sector services and developing stronger

partnerships with the key stakeholders primarily the community. Resource

allocation decisions will be made rationally, optimising the provision and

utlisation of services and resources.

The strategy includes objectives and initiatives that contribute to more than one

health outcome and include all levels of health service provision (primary,

secondary and tertiary care). For example, high priority is given to dealing with

emergency situations and disaster risk reduction and management. The DoH

also gives high priority to the provision of a minimum basic healthcare package

including promotive, preventive, curative and rehabilitative health services to the

community. The aim is to use available resources efficiently and effectively to

provide a high standard of care, as measured by international standards and to

make healthcare affordable and accessible giving preference to the poor and

marginalised. Priorities include: improving health facilities, ensuring staff


4

availability, providing functional equipment and continual and adequate supplies

of drugs and medicines.6

Planned investments in housing, education, transport, water and sanitation and

the provision of social protection will contribute to improved health outcomes.

The CDS provides the impetus for strong coordination and collaboration

between the various sectors with the role of the Planning and Development

department (P&D) being essential.

Cross-cutting strategies, for example the CDS, the Malakand Comprehensive

Stabilisation and Socio-Economic Development Strategy, the Post Crisis Needs

Assessment (PCNA) carried out for Khyber Pakhtunkhwa and Federally

Administered Tribal Areas to promote peace building must be given

consideration particularly in the development of action plans to ensure impact

and efficient utilisation of resources.7

This Strategy addresses issues, and proposes strategies designed to improve

performance across the health sector. The Strategy focuses on areas that the

government can influence and on coordination with the private and non-

government sector. It is recognised that acceptance of the strategy by the

private, non-government sector will be voluntary.

The responsibilities of different levels of government (Federal, Provincial and

District) are now undergoing a major review following the abolition of the Local

Government Ordinance of 2001, the 7th National Finance Commission (NFC)

award and the passage of the 18th Amendment to the Constitution. This has

changed the mandate of several Federal Ministries including the Ministry of

Health (MoH), and expanded the role and responsibilities of institutions and

administrative structures at the provincial level effective from 1st of July, 2011.

These changes will influence the terms of engagement of international partners

with both the federal and provincial governments.

These developments give impetus to the plan to review the role and

subsequently the organisational structure of the DoH. It is likely that the DoH

will focus more in the future on stewardship, regulation of health service

provision, managing potential innovations in financing mechanisms for health

6 Comprehensive Development Strategy

7 Comprehensive Development Strategy

Introduction

5

care provision, and developing policies and initiatives that support synergies and

reduce duplication in service provision between the private sector and public

sector.

The Strategy document

Part 1 of this draft strategy outlines the challenges for each health outcome.

Part 2 identifies key objectives and strategies to ensure improved health

outcomes.

Part 3 gives the list of performance indicators for the strategy from 2010-2017

Part 4 gives an analysis of health expenditure including an analysis of the gap

between expenditure and CDS projections.

Part 5 provides the funding implications of the activities identified in the strategy

Part 6 provides the Implementation and Monitoring mechanism for the Strategy

Annex 1 describes the strategic development process and lists the stakeholders

who were consulted.

A separate volume provides additional information on the current situation for

the health sector in Khyber Pakhtunkhwa province.


0

Part 1. Challenges for each health

outcome area

Outcome1: Enhancing coverage and access

to minimum health services especially for

the poor and vulnerable

Challenges8

High levels of poverty and inequity adversely affects the health

status of the population

The population of Khyber Pakhtunkhwa has increased from 17.7 million in 1998

to 22.2 million in 2009. In addition it is estimated that there are more than 3

million Afghan refugees living in the province.

Over half the population is illiterate9 and 31 percent of the population is living

below the poverty line with the highest levels of poverty in Shangla, Upper Dir,

Bunair, Kohistan and Battagram. There is also a wide variation between districts

in resource allocation, disease prevalence, malnutrition, gender inequality and

illiteracy. Only 47% of the households have tap water and 61% have safe

sanitation10 leading to a high prevalence of water borne diseases.

High out of pocket expenditure for health care

Household out-of-pocket (OOP) spending remains the main source for financing

healthcare. There is minimal social protection and a lack of access to health

insurance. Khyber Pakhtunkhwa’s share of out-of-pocket expenditure for health

8 The issues/challenges for each health outcome were either evident in the available

research, the CDS and the draft of the National Health Policy (2010), or were expressed

in the consultative workshops and/or the key informant interviews.

9 As quoted in the CDS, from NWFP Development Statistics, NWFP White Paper, 2008-

2009 page VII

10 As quoted in the CDS, from NWFP Development Statistics, NWFP White Paper, 2008-

2009 and sourced from the Demographic Health Survey

Challenges for each health outcome

1

care (76.6%) is the highest of all provinces.11 An analysis in 2002 showed that

over 90% of expenditure on drugs and medicines in the Province was private

and that nearly 60% of expenditure on health was paid by households.12 With

the high percentage of people below the poverty line, the cost of healthcare can

result in families becoming completely impoverished.

Conflict and natural disasters13

Recently the DoH has faced multiple challenges due to the law and order

situation in the province. The DoH has had to respond to the manmade or

natural disasters; maintain routine services at the district level and provide

services to internally displaced persons (IDPs).14 At the peak of the insurgency

in the past three years around 2.7 million civilians were displaced due to

militancy. While most have returned to their homes, it is estimated that over

260,000 people (37,000 families) have been displaced (registered and verified)

from Waziristan mainly to DI Khan and Tank districts. Kurram Agency has also

been insecure and a large number of families have moved as IDPs to Kohat,

Hangu and Peshawar districts.

In affected areas, nearly a third of health facilities including hospitals, Rural

Health Centers (RHCs) and Basic Health Units (BHUs) are damaged with an

estimated reconstruction cost of Rs. 942.4 million.15 However, a detailed

technical assessment is under way which will show the real damages and cost

implications.

11 National Health Accounts 2005-6

Lorenz. C., Khalid. M., Regional Health Accounts for Pakistan- provincial and district health

expenditures and the degree of districts fiscal autonomy. 2009 accessed from

http://www.pide.org.pk/psde/25/pdf/Day2/Christian%20Lorenz.pdf

12 OPM Health Accounts, 2002

13 Pakistan Humanitarian Response Plan 2010, United Nations from website browsed on

12th May 2010. http://ochaonline.un.org/humanitarianappeal/webpage.asp

14 Government of Khyber Pakhtunkhwa ‘Comprehensive Development Strategy, 2010-

2017’ April 2010

15 Preliminary Damage & Needs Assessment; Immediate Restoration and Medium Term

Reconstruction in Crisis Affected Areas Prepared by Asian Development Bank and World

Bank for Government of Pakistan Islamabad, Pakistan November 2009 – page 9.

http://www.pide.org.pk/psde/25/pdf/Day2/Christian%20Lorenz.pdf

http://ochaonline.un.org/humanitarianappeal/webpage.asp


2

The region had not recovered from the effects of the 2005 earthquake and the

insurgency, when it was hit by widespread floods in July and August 2010.

These natural disasters led to widespread homelessness and destruction of

infrastructure.16

Low level of women and children’s health status

Women and children are particularly disadvantaged by socioeconomic and

cultural barriers with estimates of only 30% of them having access to medical

care.17 The total fertility rate is high and the contraceptive prevalence rate

(CPR) is not rising fast enough to achieve the MDG goals. There is high

maternal and infant mortality and services are insufficient (see challenges in

Health Outcome 2 below).

Insufficient provision of high quality public health care services.

Public as well as private services focus on curative care, with little attention to

promotive, preventive or rehabilitative care. In addition, there is little known

about the community’s priorities in relation to primary health care services.

. Chronic staff shortages and non-availability of essential medicines is common

and leads to health facilities being underutilised due to shortages of staff and

supplies. In the Community Information Empowerment and Training (CIET)

survey (2004), only 9% of the patients who had used a government facility had

received all of their prescribed medicines.18

The quality of service provided by public health care providers is variable.

Typically consultations between patient and health worker are short19, antibiotics

16 Results of a rapid assessment carried out 11 districts of Khyber Pakhtunkhwa that nearly

257,184 households have lost their homes or have been temporarily displaced.

17 http://www.ayubmed.edu.pk/JAMC/PAST/20-4/Moazzam.pdf

18 http://www.ciet.org/en/documents/projects_library_docs/2006224175348.pdf

19 .One study found that the contact time of doctors per patient is less than two minutes. The

average number of drugs per prescription was nearly 3 with only 1.5 drugs being

dispensed from the facility. Half of the prescriptions contained antibiotics and 17% of

patients were prescribed with injectables.

http://www.ciet.org/en/documents/projects_library_docs/2006224175348.pdf


3

are over-used, poly-pharmacy, there is poor communication between patient

and dispensing staff and inadequate dispensing techniques.20

There is a lack of capacity both at the provincial and the district level to respond

to emergencies, epidemics and disasters appropriately. There are only a small

number of ambulances available, often without trained staff. Provision of

emergency services is hampered by 44% of the provincial roads and 78% of

district roads being in poor or bad condition. 21 Demand for emergency services

has increased after the 2005 earthquake, bomb blasts resulting in mass

casualties, and the increase in road traffic accidents. While services for

rehabilitation, including the provision of orthotics and artificial limbs have

improved, demand is far from being met.

A significant number of people, particularly in remote rural areas have difficulty

accessing primary healthcare.22 Where there is no local facility within the

community, the average distance to a health facility is about 10 kilometres in

rural areas, roughly three times the distance in urban areas.23 Given the size of

the rural population in Khyber Pakhtunkhwa, there should be over 380 RHCs

and over 1280 BHUs. There are however only 86 RHCs and 784 BHUs, in the

province.24

By 2008, there were over 13,000 Lady Health Workers (LHWs) in the province

providing nearly 12 million people with access to their services. Each LHW is

responsible for providing care to a catchment population of around 1,000 people

in rural areas. However the National Programme for Family Planning and

Primary Health Care (NP FP&PHC) does not yet cover the full targeted

population.

20 http://www.jpma.org.pk/PdfDownload/381.pdf

QOC survey findings.

21 Government of Khyber Pakhtunkhwa ‘Comprehensive Development Strategy, 2010-

2017;, April 2010

22 The PSLM survey in 2007/08 found that 43% of the people in rural areas who sought

treatment for diarrhea and who did not visit a government facility first gave as the reason

that either there was no government facility or it was too far away. A further 15% said that

a doctor was never available and a further 13% that the staff were not courteous.

23 MICS 2008 for Khyber Pakhtunkhwa

24 DHIS, April 2010

http://www.jpma.org.pk/PdfDownload/381.pdf


4

Weak referral system

The failure of the referral system contributes to the underutilisation of primary

healthcare facilities, resulting in high unit costs. This failure can be attributed to

health worker attitudes in addition to social, economic and organisational factors

which need to be understood. Weak organissational and functional linkages

between the district health officers and the medical superintendants of District

Headquarter (DHQ) hospitals, contributes to a lack of integration between

primary and secondary level health services.

Outcome 2: A measurable reduction in

morbidity and mortality due to common

diseases especially among vulnerable

segments of the population.

Challenges

Improving access for health care for women and children

The recent Pakistan Demographic and Health survey (PDHS) has established a

Maternal Mortality Ratio (MMR) for the province of 275 maternal deaths per

100,000 live births. Most of these deaths are caused by postpartum

hemorrhage, puerperal sepsis or due to eclampsia. Despite the adverse

conditions in the province, child mortality rates are better than the national

average. The neonatal mortality rate is 41 per 1000 live births, while the infant

mortality rate is 63 and under-five mortality rate is 75. The attendance of skilled

birth attendants (SBAs) at delivery has increased significantly from 28 % in the

MICS 2001 to 41% in the MICS 2008.25

At present only 50% of women in the province receive any form of ante-natal

care and only 25% are receiving any form of post-natal care from a SBA (MICS

2008). There is a lack of SBAs available in the community. The new community

midwife scheme will require ongoing support from the DoH for the training,

deployment and establishment of community midwives (CMWs) in their

25 The recall period in the present survey is for the two years preceding the survey and in

the previous survey it was one year.

Commented [TJL1]: National averages to compare to?


5

communities. In 2008 there were 737 CMWs students training under the

Maternal and Neonatal, Child Health (MNCH) programme and 22 graduated

CMWs had been deployed to their villages in the province.26

A survey showed that emergency obstetric care (EmOC) services are available

at only 34% of hospitals. Although 75% of district headquarter hospitals (DHQs)

provide comprehensive EmOC services, none of the RHCs provide these

services.27 One limiting factor in expanding coverage is the availability of female

doctors.

Fertility: The total fertility rate for the province is 5.6 children (MICS 2008). The

CPR was measured at 38% in the MICS 2008 and is significantly higher than the

31% measured by the same survey seven years previously. The CPR however it

is not rising fast enough to achieve the national MDG target of 55% and only

20% of women are using modern methods (sterilisation, pill, IUD, injection,

condom).28 The CPR is higher in urban areas, and varies significantly between

districts. The unmet need for family planning has been estimated at 26%, down

from 35% in the MICS, 2000/01.

Childhood mortality: In Khyber Pakhtunkhwa early childhood mortality rates

are high; though lower than the national average. Neonatal deaths are almost

entirely due to birth asphyxia, sepsis or prematurity while deaths in the post-

neonatal period are mostly due to diarrhea or pneumonia. The main causes of

child deaths are diarrhoea and pneumonia together with injuries, measles and

meningitis (PDHS 2006-07).

Malnutrition: In Pakistan, although the entire population is at risk of

malnutrition, children under the age of five years and pregnant and lactating

women are the most vulnerable. The results for the province, from the latest

National Nutrition Survey (2001/02) show 37% of children are underweight, 43%

of children suffer from stunting and 11% are wasted.

The MICS (2008) found a higher percentage of children from rural areas are

exclusively breastfed (46%) than urban areas (35%) and a dose of vitamin A

26Government of Pakistan submission to ‘Convention on the Rights of the Child’, 1

September 2009, to the Committee of the Rights of the Child, 52nd session,

www2.ohchr.org/english/bodies/crc/.../CRC.C.PAK.Q.3-4.Add.1.doc

27 http://www.ayubmed.edu.pk/JAMC/PAST/20-4/Moazzam.pdf

28 MICS 2008 for KHYBER PAKHTUNKHWA

Commented [TJL2]: In the province or nationally?


6

supplement had been given to 63% of children aged 6–59 months in the six

months prior to the survey.

Reducing the prevalence of communicable diseases

Communicable diseases are the most important health problems in Pakistan.

Common causes of death and illness are; acute respiratory tract infections,

diarrhoeal diseases, malaria, tuberculosis and vaccine preventable infections.

Epidemic prone diseases such as meningococcal meningitis, cholera, hepatitis

and viral hemorrhagic fevers are also prominent health threats.29

Acute respiratory infections and diarrhoea: Pneumonia remains a leading

cause of child mortality accounting for a quarter of all post neonatal deaths30 with

most deaths caused by a failure to seek treatment at a health facility. Diarrhoea

accounts for over 10% of all deaths among children in Pakistan. In Khyber

Pakhtunkhwa only 40% of children with diarrhoea are taken to a health provider,

far fewer than in other provinces of Pakistan. The MICS survey (2008) found

that 43% of children in Khyber Pakhtunkhwa under-five had recently had

diarrhoea; only 36% of these had received oral rehydration therapy or increased

fluids with continued feeding.

Polio: Pakistan is one of the four remaining countries, where polio is endemic;

29 of the 89 confirmed cases in 2009 were from Khyber Pakhtunkhwa.31 By May

2010, seventeen cases had been reported of which five were from Khyber

Pakhtunkhwa, two from Peshawar and one each from Swat, Charsadda and

Lakki Marwat.32

Tuberculosis (TB): TB accounts for 5.1% of the total national burden of disease

with approximately 1.5 million people in Pakistan living with the disease. The

case detection rate in the province has improved since the launching of National

TB Control Programme, and the initiation of Directly Observed Treatment Short

29 Economic survey 2006-07

30 National Institute of Population Studies and Macro International Inc., “Pakistan

Demographic and Health Survey 2006 – 2007,” National Institute of Population Studies,

Islamabad: 2008

31 Global Polio Eradication Initiative website http://www.polioeradication.org/casecount.asp

32 Senior Surveillance Officer, WHO Polio Eradication Initiative 12th May 2010.

http://www.polioeradication.org/casecount.asp


7

Course (DOTS). Country wide, the detection and treatment rate has improved

from under 30% in 2002 to above 80% in 2007.

HIV/AIDS: Pakistan is considered to have a low-level HIV/AIDS epidemic in

general population with a prevalence rate of less than 0.1%. However,

surveillance results have found the rate to be increasing among high-risk

groups.33 Its prevention through public health education is important.

Malaria: Around half a million people each year are affected by malaria in

Pakistan with 20% of these from Khyber Pakhtunkhwa. Only 3% households in

Khyber Pakhtunkhwa were found to have at least one mosquito net in their

possession and a meager 0.1% actually used the mosquito net (PDHS 2006-7).

The Annual Parasitic Incidence (API) however has reduced from 2.18 in 2005 to

1.5 in 2008.34

Hepatitis: The provincial government has recognised hepatitis as a priority

health problem . A number of programmes have been developed to address

hepatitis including the Benazir Health Support Programme which is being

launched to provide free treatment to poor patients with hepatitis C and a

National Programme for the Prevention and Control of hepatitis which was

established in 2005. In Khyber Pakhtunkhwa all five distinct types of hepatitis

viruses, A-E are prevalent. The current estimated prevalence of hepatitis B is

0.7852 Million and for hepatitis C is 1.1778 million. Unsafe injection and

unhygienic invasive practices (dentists, barbers, beauty parlors, ear and nose

piercing etc.) appear to be major causes of the disease.35

Increasing morbidity and mortality due to non-communicable

diseases (NCDs)

Pakistan is facing an increasing burden of NCDs. Life expectancy is increasing and there is a high prevalence of risk factors. In addition to the NCDs listed below, estimates indicate that there are one million severely mentally ill and over 10 million individuals with neurotic mental illnesse within the country. Furthermore, 1.4 million road traffic accidents (RTAs) were reported in

33Government of Pakistan, Ministry of Health, National AIDS Control Program, “HIV

Second Generation Surveillance in Pakistan: National Report Round I & II 2006-07,”

Islamabad: 2005 & 2006-07

34 Annual Parasitic Incidence (A.P.I.) = Total no. of positive slides for parasite in a year x

1000 / Total population.

35 Download from www.healthnwfp.gov.pk/downloads/hepatitis.doc on 23 June 2010

Commented [TJL3]: I am not sure what is meant by this.

http://www.healthnwfp.gov.pk/downloads/hepatitis.doc


8

Pakistan in 1999, 7000 of which resulted in fatalities. In 2007 a study found that there were 2.7 RTA casualties per1000 population36

There is a lack of public awareness, health seeking behaviour and availability of

treatments for conditions such as cancer, mental illness, ophthalmologic

disease, obesity and related illnesses, hypertension and cardiac conditions.

There is also low level of service provision, equipment, and availability of staff

to address NCDs including a lack of laboratory services at the district level for

routine investigations. There is also no radiation machine for the treatment of

cancer in the pubilc facilities of the province.

Diabetes: The number of people with diabetes is increasing due to population

growth, aging, urbanisation, and the increasing prevalence of obesity and

physical inactivity. Diabetes prevalence in Pakistan is among the top ten in the

world, with around 5.2 million people living with the disease in 2000 and with

numbers likely to rise to 13.9 million people in 2030.37

Coronary artery disease: In Pakistan it is estimate that one in four adults over

the age of 40 years (26.9%) suffers from coronary artery disease. Causal factors

include the high prevalence of risk factors, including smoking (41% of men and

7% of women); high blood pressure (24% of adults), raised cholesterol (34% of

people over 40 years of age), and being overweight (28% of urban and 23% of

rural adults)38

Cancer: There are no reliable statistics available for Pakistan, but according to

WHO estimates, based on 180 cases per 100,000 population, there would be

over 200,000 cases expected annually. Based on this estimate, only 25-30% of

these cancer cases are seen by oncologists39. . Treatment and diagnosis

facilities are very limited.

Smoking: There are about 22 million smokers in Pakistan with 55% of

households having at least one individual who smokes tobacco. Nationally,

36 ROAD SAFETY IN PAKISTANJune 21st, 2007

by:Aizaz Ahmed, PE, PTOE

37 Diabetes Care May 2004 vol. 27 no. 5 1047-1053

38 Nishtar S. Population-based Surveillance of Non-communicable Diseases: 1st round,

2005; Heartfile, Ministry of Health and WHO 2006

39 Pakistan Society of Clinical Oncology (PSCO)


9

about 100,000 people die annually from diseases caused by the use of

tobacco.40

Child disability: The MICS (2008) gave an estimate of 6% of children between

the ages of two andnine having at least one disability (‘unable to’ or with ‘a lot’ of

difficulty to see, hear, move, speak and learn). Around 26% of children who are

two years old are reported as not being able to name at least one object.

Blindness: In Pakistan, 0.9% of the population is blind. In 2002-2004, the

number of blind people in the province was 0.18 million41And the biggest cause

of blindness was cataracts. Pakistan is a signatory to the global initiative “Vision

2020- Right to Sight’ and has a National Programme for Control of Blindness

(2005-2010).

Substance abuse: Recent figures estimate that there are about 6 million drug

addicts in the country.42 The prevalence of opiate use has been estimated at

0.7% of the population, for both Pakistan as a whole, and for Khyber

Pakhtunkhwa. The number of injecting drug usersin the province in 2006 was

estimated at 8,000.43 There is a link between injecting drug user and the spread

of HIV/AIDS and hepatitis C. A further challenge is the inadequate coordination

between sectors and amongst units of DoH

40 Nishtar S. Population-based Surveillance of Non-communicable Diseases: 1st round,

2005; Heartfile, Ministry of Health and WHO 2006

41 National Survey on Blindness and Low Vision, Ministry of Health, 2002-2004

42 Ministry of Narcotics Control (2009) Yearbook 2008-2009. Islamabad: Government of

Pakistan

43 The National Assessment on Problem Drug Use, 2006

Commented [TJL4]: Between?


10

Health sector coordination: There is weak coordination between different

sectors aimed at improving the health status of the population of the province.

The public and private sectors need to improve coordination as do various

government departments to effect improvements in public health.

Within the DoH there is a need for better coordination between health facilities,

District Health Offices, hospital senior management, Director General of Health

Services (DGHS) and the Health Secretariat. Collaboration needs to be

improved at the policy development level to ensure efficiency and effectiveness

in service delivery.44

Need for greater accountability at the district level for services

provided to reduce communicable diseases

Programmes addressing communicable diseases are coordinated at the district

level by the Executive District Officer – Health (EDO-H) who needs to be held

accountable for the efficiency and effectiveness of service delivery.

No linkage between resource allocation and disease burden

A disproportionate proportion of the budget is allocated to tertiary care rather

than primary and secondary care despite this being where the greatest impact

on reducing the burden of disease could be made. An analysis in 2005-06 in

Pakistan of total public sector budgetary expenditure showed that 70% was

spent on general hospitals and clinics and only 18%, on health facilities and

preventative measures. 45

There is a large variation in per capita expenditure on health between districts.

The range is from Chitral with expenditure of Rs. 334 per person to Peshawar at

Rs. 77.46

Lack of synergies with private sector

44 Management Review, External Evaluation of the National Programme for Family

Planning and Primary Health Care, Oxford Policy Management, 2009

45 Akram. M., PIDE working papers 2007: 32 ‘Health Care Services and Government

Spending in Pakistan’ 2007 Pakistan

46 From Analysis of district expenditures carried out for the Strategy Development.

Commented [TJL5]: What is the per capita spend in Khyber Pakhtunkhwa?


11

Around 7% of the population in 2005-6 reported being sick or injured,47 94% of

them consulting a health provider. The majority of those who consulted a health

care provider looked to the private sector.

The lack of records from private sector providers results in the distortion of

disease surveillance figures in areas such as TB.

Insufficient community involvement

A national survey conducted in 2008-09 found that 38% of citizens felt their

opinions were not considered by any level of government. Districts and tehsils

have not established formal processes and procedures for consulting the

general public.48 Health providers find that in some communities, a lack of

engagement by the community leaders can lead to problems in promoting

positive health practices such as vaccinations.

Low coverage of vulnerable populations

Coverage by public health programmes which address TB, malaria, hepatitis,

and other communicable diseases need to be improved to meet MDG goals.

The Roll Back Malaria (RBM) strategy has not been fully implemented in high

risk areas and there is a lack of public awareness and health seeking behaviour

among vulnerable groups.. There is increasing prevalence of hepatitis B and C

in the population. In addition there is a lack of expertise in multi drug resistance

TB (MDR-TB) and TB/ HIV co-infection (TB/HIV) requiring the broadening of the

National TB Programme (NTP) activities beyond basic DOTS.

The coverage of health services, including access to insecure areas and to

IDPs, remains a major challenge in reducing the burden of disease to vulnerable

segments of the population. The poor functioning of primary health care units

contributes to the low coverage of services. There is also a lack of specific

expertise in peripheral areas for communicable disease prevention and control.

In order to address this, coverage of LHWs and CMWs needs to be increased.

47 PSLM, 2005/06

48 Cartier, W. J., Golda, A., Nayyar-Stone, R., (2009). The Possible Reversal of

Decentralisation in Pakistan: State Policy and Citizen Feedback. Retrieved May 13, 2010,

from

http://www.google.co.nz/search?source=ig&hl=en&rlz=&q=Nayyar+Stone+Cartier&aq=f&

aqi=g8g-m2&aql=&oq=&gs_rfai

Commented [TJL6]: Not sure what is meant here

http://www.google.co.nz/search?source=ig&hl=en&rlz=&q=Nayyar+Stone+Cartier&aq=f&aqi=g8g-m2&aql=&oq=&gs_rfai

http://www.google.co.nz/search?source=ig&hl=en&rlz=&q=Nayyar+Stone+Cartier&aq=f&aqi=g8g-m2&aql=&oq=&gs_rfai


12

Risk of blood borne diseases

There is the increased risk of blood-borne diseases from unsafe blood

transfusion practices in public and private health facilities.


13

Outcome 3: Improved human resource

management

Challenges

Weaknesses in human resource management

The DoH is the second largest department in the province with more than

30,000 employees, yet the personnel section of the DoH does not have the

capacity to manage core human resource management functions.

While the health sector is very dependent on the caliber of its staff, there is

insufficient planning and budgeting to fill vacancies when they arise. Decision

makers lack data on: the number of specialist doctors, nurses and paramedics

at the district level; the number of doctors, nurses and paramedics produced

each year; how many are required and where they should be employed. There

are no forecasts of the skills required to provide high quality services and to staff

new facilities and hospitals. Little attention is given to selection, managing for

performance and providing ongoing training & skill development. For example

the human resource management information system has more than 30,000

staff and is a manual system. The databases are out-of-date and unable to be

used for decision making.

Shortage of staff prepared to work in the peripheral health facilities

Although there are adequate numbers of post graduate qualified specialists for

government facilities, there is an overall shortage of specialists especially at the

district level due to the unwillingness of staff to serve in remote areas, resulting

in vacant positions.49

Shortage of nurses and paramedics available for public-service

delivery.

Shortages continue to exist for nurses and paramedics in the public sector.

49 See Annex 2


14

The paramedic institutes provide a two year course, producing on average, 200

technicians each year. These cover a range of specialties and the technicians

are primarily absorbed in the tertiary care hospitals with the exception of the

health technologists who are typically employed in BHUs and RHCs.

The medical faculty has recently started a training program of “technologists”

aimed towards improving the education level of technicians and offering them a

university based undergraduate B.Sc. degree. The degree which is currently

offered in nine specialties will prepare the students for independent practice. .

While there are an estimated 1,250 nurses being trained each year there are still

vacant nursing positions in the public service and a shortage of applicants for

post-graduate nursing training.

Poor quality post-graduate training for doctors

Existing tertiary care teaching hospitals cannot cope with the ever increasing

demands of postgraduate medical training (not enough training slots, beds or

supervisors). Currently there is a lack of oversight on postgraduate training and

different examination standards exist in different medical colleges affiliated to

different universities. The recently amended Khyber Medical University (KMU)

act attempts to address this by requiring all medical colleges in the province be

affiliated with KMU.

Issues in ongoing skills training and professional development

The Provincial Health Services Academy (PHSA) manages six Divisional Health

Development Centres (DHDCs), a nursing college, 10 schools of nursing, six

paramedic institutes and four public health schools.

The in-service training mechanism introduced in the 1990’s and provided

through the PHSA and DHDCs is only partially functional. There are no formal

policies, national standards or guidelines to ensure that health care providers

have up-to-date skills and knowledge. There are also no programmes for

continuing medical education and systems of re-accreditation for doctors, nurses

and paramedics.

There is also a lack of professional training and development opportunities for

medical and paramedic staff in peripheral areas and a lack of training for the

provision of medical care at the primary health care level.


15

Curriculum for health professionals not competency based.

All the medical, paramedic and nursing colleges are using outdated curriculum.

They have not implemented the revised curriculum andsyllabus developed by

the Pakistan Medical and Dental Council (PM&DC). There are also insufficient

and in some cases poorly qualified staff and/or staff who are unskilled in modern

teaching methods. No structured continuing professional development facilities

or on the job training for faculty are provided for students.

There are a large number of medical colleges in the private sector. The quality

of education at these medical institutions is fraught with issues and generally

their educational standards are considered unsatisfactory. The KMU has been

mandated to monitor the examinations of private sector colleges.

Commented [TJL7]: Not sure what is meant here


16

Outcome 4: Improved governance and

accountability

Challenges

Inadequate emphasis on stewardship functions

Within the DoH there is a lack of clarity on the demarcation of roles and

responsibilities between the provincial and the district governments. There are

also ambiguities surrounding the roles and responsibilities between the Health

Secretariat, the DGHS and the District Health Offices, between the DoH and the

autonomous institutions and between the EDO-H and the Medical

Superintendant of the Headquarter hospitals.

Lack of results based decision making

There is a dearth of management information available. Where information is

collected it is not being used sufficiently to inform decision making, leading to a

reduced incentive to improve data quality. There has been insufficient analysis

of performance by the DoH in nationally and internationally identified priority

areas andthe District Health Information System (DHIS) has yet to be

implemented. Low accountability for performance and duty of care (within the

DoH, to the government and to the people) is also a challenge.

Historically there has been little reporting on the performance of service

provision by the DoH. Where there has been evidence of poor performance, this

has not always been addressed and problems remain unresolved. Some areas

where this has been evident include the. poor functioning of first level care

facilities; little implementation of hospital autonomy; lack of effective information

systems and the filling of vacant positions.

Lack of clear strategy on public financing and alternate service

delivery models (including public-private partnership, and hospital

management)

Public-Private partnerships need to contribute to the strengthening of social

safety nets in disadvantaged settings and should be set within the context of

‘social responsibility’. The delegation of service delivery, in particular essential

health services, is currently being evaluated. The contracted management of


17

health facilities has, in the initial period, faced challenges. Problems have partly

arisen due to the lack of incentives and monitoring mechanisms to ensure the

delivery of preventive and promotive care50..

Another area of public/private partnership has been the government secondary

care hospitals which are being managed by the private sector with the

agreement that they will upgrade the hospital to provide tertiary care services

and post-graduate training. This agreement however is not being monitored.

Poor health management

Patronage is still perceived as driving promotions and transfers.51 Recruitment

processes tend to be non-transparent and the performance management

system is not being used for performance management. Performance

management is annual, confidential and used for promotion purposes, in

addition, the results are not shared with staff or used for setting targets or

improving skills. The need for experienced and competent health managers with

leadership qualities has led to the establishment of a Health Management

Cadre. However, while the seniority lists of the officials comprising the

management cadre has been notified by the DGHS there are still disputes over

the selection criteria, quality of public health qualification and litigation over the

seniority list. There is also limited supervision of the health facilities by either

District or Provincial supervisors.

Weak capacity to deliver on new roles or functions

The DoH has historically shown little capacity to deliver on new roles or

functions. This will be an issue with any additional responsibilities under the 18th

Amendment.

Inadequate financial accountability and internal controls

There is a lack of accountability for the efficient and appropriate use of funds for

the provision of services and no internal audit function within the DoH. Access to

and use of additional funding for health care from the 7th NFC award,

50 The Contracting Processes of the Health Department NWFP 2007-08

51 An Overview of the Health Sector: The Way Forward, Islamabad, Pakistan, Ministry of

Health 2001


18

development partners, and any budget allocation arising from transfers of

national programmes should be on condition of increased financial

accountability.


19

Outcome 5: Improved regulation and quality

assurance

Challenges

Lack of implementation of quality standards

Regulation of the health sector, both private and public is underway with the

establishment in 2006 of the Health Regulatory Authority (HRA). The HRA has

to-date registered around 1100 private practitioners. However, while health care

standards have been developed, they are yet to be implemented. The Improving

Quality of Health Care Services (IQHCS) initiative however has been launched

to improve the quality of care in the public sector.

Failure to provide a regulated environment

The reforms of the public health sector implemented under the National Health

Policy (NHP) of 2001 focused on publicly provided health services, essentially

ignoring private sector provision. Whilst private facilities are being registered, it is

not based on evidence of their ability to meet quality standards.52

The secondary care hospitals managed under contract by the private sector are

not being monitored to ensure that they are providing tertiary care and post-

graduate training opportunities as contracted.

There is also no council for the registration, regulation and monitoring of

paramedics.

There are many different categories of non-allopathic service providers who deal

with patients in a wide variety of settings and these providers are unregulated.

There are more than 50,000 Hakims/Tabibs and 450 Vaids registered with the

National Council for Tibb as Medical Practitioners (Tabibs/Vaids). Registration is

limited to those providers who have certificates from the National Council of Tib

and the National Council of Homeopathy.

Inadequate drug control

52 Final Report Quality of Health Care Survey, North West Frontier Province, Pakistan,

2007


20

Drug procurement is a major element of health expenditure (mainly out-of-

pocket). The Drug Control Administration inspects facilities involved in

production, distribution, sale and dispensing of medicines to ensure adherence

to relevant regulations regarding drug price controls. The Drug Control

Administration however does not have sufficient monitoring capacity.53 In

addition, drugs are not being registered by their generic names as required in by

the Drugs Act 1976; quality control laboratories do not meet WHO standards;

there is no legislation for ayurvedic, herbal products (not defined as drugs) and

there is no standardisation for the manufacturing and sales of products, provided

by alternative health care providers. Drug Rules for Khyber Pakhtunkhwa were

last developed in 1982 and except for minor amendments have not been

revised.

Food safety is not ensured and the incidence of food borne diseases are

increasing unchecked. Unhygienic conditions and attitudinal

issues further aggravate these problems. In addition, drinking

water is not fit for drinking and water borne diseases are causing

morbidity and mortality.

As a paradox, legislation does exist to address food safety such as the

Food Act although this is yet to be implemented due to the cross-

departmental responsibilities involved.. The lack of collaboration

among the relevant departments (Health, Food, Agriculture, Public

Health Engineering Department and Local Government) has

resulted in an implementation lacunae. The area of Water and

Sanitation is also neglected by the health sector. No elaborate

policies and strategies prevail to address and implement the

standards for drinking water.

53 The Network Consumer Protection ‘Prices, Availability and Affordability of Medicines in

Pakistan’ August 2006

Key objectives and strategies

HLSP, 5 – 23 Old Street, London EC1V 9HL 21

Part 2. Key objectives and strategies for

each health outcome

Outcome 1: Enhancing coverage and access to essential health services, especially for the poor

and vulnerable.

Key Objectives by 2017

1. At least 70% of the population will have access to the Minimum Health Service Package

(MHSP) for primary and secondary healthcare services.

2. Increase the contraceptive prevalence rate (CPR) to 55%.

3. Each Division of Khyber Pakhtunkhwa will have a functional category A hospital (tertiary care

hospital).

4. 60% of the population will have access to Accident and Emergency services, meeting optimum

standards, within forty five minutes of their residence.

5. 40% of the population living below the poverty line will have a form of social protection against

catastrophic health expenditures.

6. 40 % of people with non-communicable diseases will receive quality care and have access to

preventive education.

Strategies Actions



1. Implement the MHSP at Primary Health Care Level

a) Include services in the MHSP to be provided by all primary health

care units and outreach services e.g. BHUs, RHCs, LHWs, CMWs,

Expanded Programme on Immunisation (EPI) technicians.

In addition to ongoing services at the primary health care level, emphasis

will be given to the following:

Revitalising the delivery of family planning services in public sector

health facilities with a mechanism for forecasting contraceptive

requirements and ensuring the uninterrupted supply of

contraceptives to the facility, LHWs and CMWs,

Mental health

Health education

Dental care

Non-communicable diseases

Management of notifiable diseases.

b) Finalisation and costing of MHSP at Primary level.

c) Re-designate first level care facilities (e.g. Civil Dispensary (CD)

and mother and child health(MCH) centre to BHUs) in the light of

MHSP.

d) Conduct an assessment and identify gaps in service provision

against the MHSP at primary level.

e) Develop a comprehensive proposal for filling in the gaps.

f) Upgrade health facilities on the basis of need and according to

criteria established by the DoH. This may include a new design for

health care facilities depending on services agreed in the MHSP

and quality standards.

g) Develop a communication strategy to ensure the community is

aware of the services to be provided.

Commented [TJL8]: Communicable diseases ????



2. Increase consideration for equity in decisions on resource allocation

a) Allocate resources for the primary level according to health status,

demography and poverty level of a district. For the secondary level,

resources to be allocated according to performance indicators which

will include but not be limited to outpatient services , bed

occupancy rate and average length of stay, cost effectiveness of a

programme/ policy, and poverty levels.

b) Resource allocation and its criteria should be reviewed every two

years.

c) Strengthen the implementation of Output Based Budgeting in the

DoH.

d) Improve estimates on the incidence and prevalence of diseases

with analysis based on surveillance systems, surveys, the DHIS and

on poverty levels as measured by the relevant

institutions/departments such as the Federal Bureau of Statistics

(FBS) and by the Benazir Income Support Programme (BISP).

3. Improve emergency response

a) Strengthen accident and emergency (A&E) response centres with

defined standard operating procedures in all DHQ hospitals.

b) Ensure the availability of skilled staff and equipment for A&E.

c) Establish trauma care and burn units at divisional /teaching level

hospitals.

Development and

implementation of a

MHSP at secondary

level.

a) Develop a MHSP at secondary level proper costing.

b) Include in the secondary care service package the necessary

staffing levels/skills mix, equipment and supplies.

c) Re-designate secondary level care facilities in the light of MHSP.

Commented [TJL9]: Performance?



d) Upgrade health facilities on the basis of need and according to

criteria established by the DoH. This may include a new design for

health care facilities depending on services agreed in the MHSP

and quality standards

e) Outline pathways for referral and handling of emergencies using

information communication technology (ICT) with an objective of

improved linkages with primary and tertiary level facilities.

f) Include in the package: dental care; psychiatric services; treatment

and management of NCDs and rehabilitative services.

g) Conduct an assessment against the package and develop a

proposal for filling the gaps.

h) Pilot tele-health to support the provision of specialised care to the

poor in remote areas of the province

i) Define the management structure and expertise required to ensure

high quality provision of these services at District and Tehsil

Headquarter hospitals and recruit and train accordingly.

j) Explore other options to improve services at the secondary level

such as district hospital autonomy and contracting out of hospitals.

4. Define a mechanism to protect the poor and underprivileged population by reducing out of pocket expenditure.

a)

b) Analyse existing services in terms of safety nets or free services to

the poor community and develop a feasible proposal The proposal

will asses tje different options of risk pooling and social protection,

implementing the most suitable option. Options may include a micro

health insurance scheme for coverage of indoor services for the

poor or launching a voucher scheme to improve access to a defined

package of services for the poor.

c) The ultimate objective of any intervention will be to move towards

universal coverage and a reduction in OOP expenditure,

d) The DoH will collaborate with the BISP, Zakat, Baitul Maal and other

Poverty Reduction programmes in the province to ensure efficient



and effective use of funds in the health sector.

e) Pilot tele-health to support the provision of specialised care to the

poor in remote areas of the province .

5. Construction and upgrade of hospital/facilities on need basis.

a) Mapping of facilities and hospitals in the public and private sectors.

b) Identification of appropriate sites for the construction of new

facilities and the upgrade of existing facilities against an approved

feasibility criteria.

c) Focus on the provision of Specialised Health Care to address

emerging and prevailing health problems.

d) The construction of specialised units, hospitals and institutions will

be considered on priority especially in those areas where even

private sector is not providing services.

e) Explore the opportunities of purchasing services from the private

sector under a public private partnership arrangement.

6. Improve rehabilitation services

a) Strengthen rehabilitation services through the provision of support

to Benazir Hospital in Peshawar, Ayub Medical College, PIPOS and

the Paraplegic Centre.

b) Provide selected rehabilitative services including ensuring

appropriate staffing from tertiary care hospitals up to the Tehsil

Headquarter Hospital (THQ).

c) Establish and develop, properly equipped rehabilitation centres at

Type A divisional hospitals with relevant sentinel sites at district

level).

Commented [TJL10]: ???



Outcome 2: A measurable reduction in morbidity and mortality due to common diseases especially

among vulnerable segments of the population.


1. Reduce the maternal mortality rate to 140 per 100,000 live births.???

2. Reduce the infant mortality rate to 40 per 1000 live births with an emphasis on reducing

newborn deaths.????

3. 10% reduction in the prevalence of underweight children under 5 through the use of nutrition

intervention programmes.

4. Increase exclusive breastfeeding to 65%.

5. 90% of children under five to receive vaccinations according to EPI schedule.

6. Reach zero transmission of the polio virus by 2011.

7. 90% of children under five to receive appropriately timed Vitamin A supplementation.

8. Reduce the prevalence rate of hepatitis B and C in the general population to less than 5%.

9. Increase the detection of TB cases to over 70% of sputum positive cases.

10. 85% of registered TB cases cured using DOTS.

11. 25% reduction in the number of malaria cases by implementing the RBM Strategy.

12. Maintain the prevalence rate of HIV/AIDS to less than 1% among vulnerable groups.

Strategies Actions

1. Integrate national health programmes into a package of services provided at primary, secondary and tertiary levels.

a) Review the PC 1s of different projects.

b) Develop a proposal for an integrated programme whilst keeping

the prioritised areas and programmes/projects in consideration

c) Implement one or two programmes focussing on the priority

areas of MDGs in the shorter term until the full implementation

of the MHSDP.

d) In the longer term, run these services as an integral part of the

MHSP for Primary Health Care (in Outcome 1).

Commented [TJL11]: Do not know what is meant here



2. Develop institutional mechanisms to ensure intersectoral/ departmental collaboration to improve the health status of the population

a) Strengthen institutional mechanisms to increase

collaboration between sectors through the following

steps:

Form an interdepartmental coordination committee

on health. This committee will comprise the relevant

departments, headed by the Minister of Health.

Review by the Annual Development Programmes

(ADPs) Planning and Development (P&D)

department of relevant departments, to promote

synergies in areas affecting health.

b) Strengthen cooperation and collaboration within

the DoH through:

Coordinate meetings at secretariat level with autonomous

institutions including the Health Sector Reform Unit

(HSRU), planning cell, monitoring and evaluation (M&E)

Cell, DGHS and all other allied institutes on regular basis.

Draft Budget and ADP may formally be shared with the

committee with representation from the relevant

institution. Their inputs may be incorporated before

submitting to the Finance and P&D Department.

Quarterly meetings of different programmes and EDO-Hs

under the chairmanship of the DGHS.

3. Develop and implement a strategy for nutrition intervention???

a) Finalise and approve a Nutrition Programme including

appropriate interventions to improve nutrition, especially of

women and children.

b) Promote exclusive breastfeeding in the province through

raising public awareness using media, and promotion of

breastfeeding in all hospitals, health facilities and outreach

services.

c) Develop the capacity of relevant staff to identify and manage

malnourished children at early stage.

d) Ensure the availability of relevant supplies as part of MHSP at

Primary and secondary levels.



4. Develop and implement a strategy for reducing neonatal deaths.

a) Include improvement of newborn health as an important

element of the MHSP at primary and secondary level.

b) Develop the capacity of relevant staff to identify and manage

neonatal problems appropriately.

c) Implement necessary training e.g. Integrated Management of

Neonatal and Childhood Illnesses (IMNCI) training at all levels

of the public health care system and facilitate the training of

private providers.

d) Raise public awareness through the media and LHWs to

recognise danger signs in newborns and the importance of

seeking early healthcare.

e) Establish Neonatal Intensive Care Units (NICUs) with

appropriately trained staff at least at all division level hospitals.

5. Implement the strategy for reducing hepatitis B&C

a) Establish screening and diagnostic centres at all teaching and

DHQ hospitals.

b) Improve healthcare provider and community knowledge on the

mode of spread of hepatitis B&C and on preventive measures.

c) Establish safe blood transfusion practices in all public and

private sector hospitals and blood banks.

d) Establish a hospital waste management system in all public

sector hospitals.

e) Strengthen routine immunisation services for the hepatitis B

vaccine for infants through the provision of immunisation in

children under one using the Expanded Program of

Immunisation infrastructure.

f) Promote hepatitis B vaccinations amongst adults.

g) Facilitate/ provide treatment facilities for poor patients .

Improve emergency and

epidemic response.



a) Establish a budget line for the additional burden of

emergencies and IDPs.

b) Strengthen Surveillance systems in Health Sector.

Assessment of Disease burden:

a. Regular scientific studies on the burden

of Disease will be conducted .

b. Appropriate interventions on the basis of

studies to reduce the burden will be

introduced.

c. Ensure the distribution of funds as per

the burden of disease and utilisation of

institutions and facilities.



Outcome 3: Improved human resource management


1. 90% of budgeted positions in the DoH are filled through a transparent and competitive

selection process.

2. 70% of all staff meet the skill requirements of their position.

3. All medical colleges should fulfil minimum criteria for recognition by Pakistan Medical and

Dental Council and meet the quality standards.

4. All nursing and paramedic institutes would be registered with their relevant registering bodies

and meet the quality standards.

Strategies Actions

1.Strengthen the personnel

section to perform human

resource management

functions optimally

a) Review the current functions and staffing of the personnel

section with a view to reorganising it in order to improve its

human resource management functions.

b) Personnel section will facilitate decision makers by providing

necessary evidence. In the first three years of operation, the

personnel unit will be responsible for:

c) Streamlining/updating information regarding currently employed

professional and technical staff. This information will be linked

with the GIS DHIS and PIFRA.

d) Development of a Human Resource Development plan

covering:

a. Forecasting of human resource needs based on the

human resource requirements of the department.

b. Budgeting of staffing requirements for professional,

medical and technical staffing for all public health

institutions in the province.

c. Developing an overall policy for the management of the

education of medical, nursing and paramedic and allied

fields including continuing professional development.

d. A costed plan of action to fill the gaps where feasible.

e. A mechanism for regular updating and reviewing the

plan. Improve the availability of appropriately skilled

human resources for service delivery

Develop policies and rules for staffing peripheral health institutions with


Commented [TJL13]: ????



appropriately skilled staff and female service providers including

nurses. This might require enhanced salaries, career opportunities,

perks and privileges, providing reasonable accommodation, high quality

schooling for children and security.

Explore the proposal to train male nurses.

Explore the options of rotating those undertaking postgraduate training

through district health facilities.

Develop a continuing medical education mechanism for all nursing,

medical and paramedical staff linked to career development.

Develop/establish a council for the registration of paramedics and

accreditation of paramedic institutes.

2. Improve the quality of

training

Develop and implement a competency based curriculum at all levels.

The DoH will direct and facilitate the respective institutions/bodies in

reorienting their curricula and training to being competency based, with

enhanced exposure to the community, and with responsiveness to local

needs and compliance with international standards.

Establish a department of medical education in each medical college.

Review the assessment and examination systems of the training

institutions to bring them in to line with national/international standards

(e.g. , SEQs, OSCE and internal evaluation).

Establishment of a skills workshop in each training institute for ensuring

medical students, nurses and paramedics practice and develop skills

initially on manikins instead of patients.

Consult with the PMDC and CPSP to explore the feasibility of:

PGMI monitoring all postgraduate medical training in the

province.

Ensure that the MBBS exams in all medical colleges in the

province (private and public) are conducted by KMU to ensure

a consistent standard and for KMU to be funded accordingly.

Improve linkages and knowledge sharing by pairing each

district to a teaching institution so that the latter can provide

technical support and supervision to the former.

Training Institutes to provide compulsory induction, promotion and

refresher courses under the supervision of the PHSA and DHDC.

These should include knowledge on government rules and regulations,

Commented [TJL14]: ????


Commented [TJL16]:


Commented [TJL18]: Not sure what is meant here. Taken at KMU?



essential functions to be performed, job descriptions, communication

and ethics, and guidelines for national and international commitments

such as the MDGs.

Introduce continuing medical education, in medical and nursing

education at all levels with links to promotions.

Improve the quality of nursing through the:

Introduction of a B.Sc. Nursing as a standard requirement for

nurses as well as the introduction of a range of post-graduate

nursing qualifications.

Provide stipends for post-graduate nursing education.



Outcome 4: Improved governance and accountability


1. To be accountable to the government and citizens of Khyber Pakhtunkhwa for providing health

services which meet the established service standards and serve the target population.

2. 80% of the reports of the DHIS would be received on time according to protocols.

3. Policy, resource allocation and flow of funds demonstrably match the needs of target

populations ascertained by the DHIS and other programme MISs.

Strategies Actions

1. Strengthening of stewardship function

Review by the DoH of its roles and responsibilities. Make necessary

changes for improved functioning at the provincial and district level.

Restructure the DoH in the context of its new roles and responsibilities

including drug control and disease surveillance.

Organise in a coherent and integrated manner the policy and planning

functions of the DoH; planning and policy reform; monitoring and

evaluation; health financing; human resources and health legislation.

Strengthen the fiduciary-assurance functions of the DoH, including

financial management and procurement.

2. Improved accountability and transparency

Enable community and stakeholder participation in decision making

processes, including budget preparation and strategic review

processes.

Regular financial monitoring by the Departmental Accounts Committee

(DAC) and the Public Accounts Committee (PAC).

Establish an internal audit unit with the capacity to conduct regular

internal audits using a risk management approach.

Conduct regular external audits by the Accountant General’s office,

including systems and performance audits.

Ensure regular reviews of health outputs and budget utilisation, to be

conducted by the PHSC.

Align partners’ projects with policy outcomes of the Health Strategic

Plan and later on as part of the provincial ADP.

Develop an annual donors’ plan with mechanisms for joint

accountability.

Establish a legal unit to handle litigation cases and provide advice on

the review of rules and regulations for health care provision, legislation



relating to health issues (e.g. tobacco, breast milk substitutes, blood

transfusion, patients rights issues, drug and food acts).

Medical Ethics

3. Improving Results based management

Implement fully the MTBF in accordance with this strategy.

Employ appropriately skilled personnel for budget and financial

management positions within the DoH.

Implement the DHIS ensuring adherence to data flow protocols and

data validation.

Integrate all national programmes information systems into the DHIS

and establish functional linkages between all levels of operation

(facilities, district, provincial management).

Establish a Provincial Health Information Management Unit to:

Conduct data analysis for assessing progress on indicators.

Improve the quality and utilisation of information available for

decision making from different sources and prepare policy

options for informed decision making.

Manage the DHIS.

Collate data from the M&E reports and from programme MISs

(until such time as they are integrated into the DHIS).

Manage the DoH website.

Disseminate information on services and performance including

budgeting and expenditure information to the population and to

the media.

Develop E-government: using ICT and particularly the internet to

achieve better governance, making it more efficient, user oriented and

transparent.

4. Efficient and effective supply management systems

Operationalise the provincial public procurement rules (PPR) and build

the capacity of staff to implement these rules.

Establish a procurement and logistics management cell in the DoH.

Develop a procurement and logistics management plan (2010-2017)

based on a needs assessment exercise for all of the provinces covering

drugs, diagnostics, equipment and biological supplies. The plan will

ensure the continuous supply/replacement of each item to ensure



service quality and patient safety.

Establish biomedical workshops for each division to institutionalise

equipment maintenance scheduling.

5. Improved Health Management

Recruit on merit; ensure an internal/external competitive and

transparent process to select project managers, EDOs-H and other

management staff.

Computerise the database of all health staff including information on

transfer and posting and link with the PIFRA human resource database.

Provide regularly performance assessments with feedback to all health

staff.

Implement the policy for the development of a health management

cadre.

6. Health financing and alternative models of service delivery

Implement the MTBF fully at the provincial and district level.

Develop a health financing policy with objectives of promoting social

health protection and reducing OOP Expenditure with clear guidelines

including capacity for implementation, management and enforcement.

Develop Policy and guidelines to ensure effective public/private

partnership for management of public health facilities.

Plan the construction of new public health facilities only where there is

insufficient capacity in both the private and the public sector to provide

basic health services.

Develop policies and guidelines for ‘purchase’ of services from the

private sector by the government in areas where high quality private

sector service providers are available. In all such arrangements

provision for safety nets for the poor would be an essential element.

Decide the future of the PPHI model and other similar models in the

light of the policy for public/private partnership.

Promote the decentralisation of decision making to public sector



hospitals, especially for human resource and financial management

with the provision of support and appropriate planning. There will also

be a monitoring mechanism with performance assessments and

reviews of lessons already learned established.

Pilot different models of health financing on the basis of research to

reduce OOP expenditure, for example: voucher schemes and micro-

health insurance with the aim of universal coverage.

Review the policy of using DHQ Hospitals by private medical colleges

for teaching. Where the partnership is to be continued the respective

hospitals shall be improved to the standard of a high quality tertiary

care hospital.

7. Building capacity

Review the capability of DoH to implement the strategic plan and

accordingly restructure and build capacity for implementation.

Provide management training and development for the health

management cadre according to a schedule listed in the Health

Management Cadre rules.

Provide refresher training for all management staff (planning,

monitoring, DDO and procurement).



Outcome 5: Improved regulation and quality assurance


1. 70% of private health care institutions are registered with the Health Regulatory Authority.

2. 70% of all public healthcare facilities meet the quality standards established by the DoH

3. 30% of the registered private sector healthcare facilities meet the quality standards

established by the DoH.

4. 95% of collected drug samples meet the drug quality standards.

5. 30% reduction in incidence of food borne illnesses.

Strategies Actions

Implement the ‘quality strategy’ over the next five years with agreed areas of action where efforts can be focused for improving quality.

Implement the quality strategy in a phased manner in all districts over

the next five years.

Institutionalise the quality process in the system by establishing a

propoer set up for the purpose.

Tied grants will be used to provide incentives for the implementation of

priority standards in public sector.

1. Health Regulation

Mapping of all Private Health institutions.

Register all new clinics with the HRA once mapping is completed.

Facilitate the registration of providers and then monitor standards.

Provision of information materials and seminars on the regulations and

standards by the Health Foundation.

Implement the quality strategy of the DoH and disseminate the strategy

as a public communications document. Distribute, launch and

communicate the quality strategy to civil society as well as within the

DoH. Identify specific arrangements for publicly reviewing progress to

the quality strategy should be identified.

2. Drug Regulation Improve the quality assurance and inspection system.

Devise and implement a strategy for drug regulation based on the

redistribution of roles following the 18th Constitutional Amendment.

Formulate the legal framework, policies and procedures for

strengthening the pharmaceutical and supplies management system.

Strengthen the drug testing laboratories and establish an Appellate



Laboratory.

Promote the establishment of pharmaceutical manufacturers in the

province who adhere to good manufacturing practices.

Implement standard pharmaceutical practices including promoting the

use of generic drugs in both public and private sectors. This would

include purchasing and promoting generic drugs for the public health

facilities.

3. Food Regulation

Clarify the role of the Food Department and the DoH regarding the

implementation of the Food Act.

Conduct a study to identify key issues regarding food safety.

Strengthen the food analysis laboratory to ensure proper analysis of

samples.

Performance indicators


Part 3. Performance indicators

Source Performance Indicator

2010

-11

2011

-12

2012

-13

2013

-14

2014

-15

2015

-16

2016

-17

Means of

verification

Health Outcome 1

Health Outcome 1

Key Objective 1

(CDS+ MDG Goal)

CPR

Contraceptive prevalence rate 40% 45% 50% 53% 55% 55% 55% PIHS/MICS

Health Outcome 1

Key Objective 2

(CDS MDG Goal) Skilled

Birth Attendant

Delivery by skilled birth attendant 55% 65% 75% 85% 90% 90% >90%

MNCH

reports,

MICS

Health Outcome 1

Key Objective 3

MHSP

Percentage with access to MHSP

at Primary level. - 25% 45% 50% 55% 60% >60%




2010

-11

2011

-12

2012

-13

2013

-14

2014

-15

2015

-16

2016

-17

Means of

verification

Health Outcome 1

Key Objective 4

MTBF (1.4)

% of those below the poverty line

with social protection against

catastrophic health expenditures

- 10% 15% 20% 25% 30% 40%

Health Outcome 1

Key Objective 5

A functional category A hospital in

each division of Khyber

Pakhtunkhwa

1 2 3 4 5 6 7 HD reports

Health Outcome 1

Key Objective 6

Emergency and Trauma

services

Percentage of population with

Functional A&E centre within a half

an hour drive from their residence

20% 25% 30% 35% 40% 50% 60% DIHS, HD

reports

Health Outcome 1

Key Objective 7

Percentage of people with NCDs

receiving quality care and access

to preventive education

10% 15% 25% 30% 35% 35% 40% DHIS

Health Outcome 1

MTBF (1.1)

Primary Care

Primary health care facilities -daily

OPD attendance DHIS




2010

-11

2011

-12

2012

-13

2013

-14

2014

-15

2015

-16

2016

-17

Means of

verification

Health Outcome 1

MTBF (1.1)

Primary Care

Primary health care- no. of new

facilities established as per needs

Health Outcome 1

MTBF (1.2)

Secondary Care

Secondary health care facilities-

daily OPD attendance

Health Outcome 1

MTBF(1.2)

Secondary Care

Secondary health care- no. of

indoor patients

Health Outcome 1

MTBF (1.3)

Tertiary Care

Tertiary health care- bed

occupancy rate

Health Outcome 1

MTBF (1.3)

Tertiary Care

Tertiary health care- average

length of stay




2010

-11

2011

-12

2012

-13

2013

-14

2014

-15

2015

-16

2016

-17

Means of

verification

Health Outcome 1

MTBF(1.5)

Specialised services

No. of specialised hospitals

completed 1 1 1

Health Outcome 2

Health Outcome 2

(CDS+ MDG Goal)

Key Objective 1

Infant Mortality Rate

Infant mortality rate (per 1000 live

births) 60 55 50 45 40 38 35

PDHS,

MIMS

Health Outcome 2

CDS, MDG

Key Objective 2

Maternal Mortality Rate

Maternal mortality ratio (per

100,000 live births) 250 200 180 160 140 138 135

PDHS,

MIMS

Health Outcome 2

Key Objective 3

Reduction in prevalence of

underweight children By 10% MICS, NNS

Health Outcome 2

Key Objective 4

% women exclusively

breastfeeding 45% 50% 55% 60% 65% 65% 65% MICS




2010

-11

2011

-12

2012

-13

2013

-14

2014

-15

2015

-16

2016

-17

Means of

verification

Health Outcome 2

(CDS + MDG Goal)

Key objective 5

MTBF(2.5)

EPI

Proportion of fully immunised

children 66% 68% 70% 80% >90% >90% >90% MICS, CES

Health Outcome 2

Key Objective 6 % transmission of polio virus <2 0 0 0 0 0 0

Surveillance

reports

Health Outcome 2

Key Objective 7

Percentage of children receiving

vitamin A supplementation 80% 85% 90% 90% 90% 90% 90% MICS

Health Outcome 2

Key Objective 8

% population with hepatitis B and

C <5% <5% <5% <5% <5% <5% <5%

Survey,

DHIS

Health Outcome 2

MTBF (2.3 a)

Hepatitis B&C

No. of patients treated for hepatitis

B&C 7768 7500 7500

Programme

reports

Health Outcome 2

MTBF (2.3 b)

Hepatitis B&C

No. of patients registered for

hepatitis B&C 15,000 11,000 10,500

Programme

reports




2010

-11

2011

-12

2012

-13

2013

-14

2014

-15

2015

-16

2016

-17

Means of

verification

Health Outcome 2

Key Objective 9

MTBF (2.1)

TB

Incidence of TB/100,000 people

Health Outcome 2

Key Objective 9

MTBF (2.1a)-

TB

Case detection rate for T.B 72% 74% 76%

Health Outcome 2

Key Objective 9

MTBF (2.1-b)

TB

Treatment success rate for TB 90% 90% 90%

Health Outcome 2

Key Objective 10

MTBF (2.2)

Malaria

Reduction in no. of cases of

malaria By 25%




2010

-11

2011

-12

2012

-13

2013

-14

2014

-15

2015

-16

2016

-17

Means of

verification

Health Outcome 2

Key Objective 10

MTBF (2.2)

Malaria

% of population in malaria risk

areas using malaria prevention

and treatment measures

75%

Health Outcome 2

MTBF(2.2)

Malaria

No. of slides-Malaria 380000 400000 420000

Health Outcome 2

Key Objective 11

MTBF(2.4)

HIV/AIDS

Prevalence rate of HIV/AIDs

amongst vulnerable groups <1% <1% <1% <1% <1% <1% <1% Surveys

Health Outcome 2

MTBF (2.4a)

HIV/AIDS

No. of registered patients with

HIV/AIDS 650 700 750

Health Outcome 2

MTBF(2.4 b)

HIV/AIDS

No. of advocacy campaigns

conducted 25 30 35




2010

-11

2011

-12

2012

-13

2013

-14

2014

-15

2015

-16

2016

-17

Means of

verification

Health Outcome 3

Health Outcome 3

Key Objective 1 Fill budgeted positions 85% 85% 90% 90% 90% 90% 90%

DHIS, HD

reports

Health Outcome 3

Key Objective 2

% staff meeting skill requirements

of their positions - 40% 50% 55% 60% 65% 70% HD reports

Health Outcome 3

Key Objective 3

All medical colleges recognised by

PMDC 100%

Health Outcome 3

Key objective 4

No of schools registered by the

Pakistan Nursing Council (PNC)

and Paramedic Council.

100%

Health Outcome 3

MTBF(3.2)

No. of staff trained (induction,

refresher and promotional) 228 450 600

Health Outcome 4

Health Outcome 4

Key Objective 1

Published Annual Performance

Review against strategic plan and

MTBF




2010

-11

2011

-12

2012

-13

2013

-14

2014

-15

2015

-16

2016

-17

Means of

verification

Health Outcome 4

Key objective 2

Timely Reporting in DHIS

according to protocols 80%

Health Outcome 4

Key objective 3

Evidence based decision

making

Key decisions have a transparent

evidence base

Health Outcome 4

MTBF (4.2b)

Evidence based decision

making

No. of review meetings held by

M&E Cell 4 4 4

Health Outcome 4

MTBF (4.1)

Primary, Secondary and

Tertiary Healthcare

services

No. of facilities implementating

quality standards 80 180 240

Maybe shift

to Outcome

5?

Commented [TJL19]: Not sure what this refers to an M&E….




2010

-11

2011

-12

2012

-13

2013

-14

2014

-15

2015

-16

2016

-17

Means of

verification

Health Outcome 4

MTBF (4.3 a)

Planning and policy

making

No. of reviews by planning cell 4 4 4

Health Outcome 4

MTBF (4.3 b)

Planning and policy

making

No. of Policy proposals based on

evidence submitted by HSRU 4 5 5

Health Outcome 5

Health Outcome 5

Key Objective 1

Regulation

% of private healthcare institutions

registered with HRA 35% 55% 70% 80% 90% HRA reports

Health Outcome 5

Key Objective 2 a

MTBF (5.1)

Quality Assurance

% of public healthcare institutions

meet quality standards 35% 55% 70% 80% 70% HRA reports




2010

-11

2011

-12

2012

-13

2013

-14

2014

-15

2015

-16

2016

-17

Means of

verification

Health Outcome 5

Key Objective 2 b

Quality Assurance

% of registered private sector

health care facilities which meet

standards

50%

Health Outcome 5

Key Objective 3

MTBF (5.2)

Drug Control

% of Drug samples tested in

laboratory which meet quality

standards

1,500 1,500 1,500 95%

Health Outcome 5

MTBF (5.3)

Food Control

No. of legal actions taken on poor

quality samples.

Health Expenditure


Part 4. Health expenditure

Health financing and expenditure

Health financing

The Comprehensive Development Strategy costs the priority health measures for the

province at Rs 106 billion which represents 11% of the total Rs 960 billion CDS outlay over

the next seven years. Of the total cost: Rs 60 billion is for recurrent costs and Rs 46 billion

is for development costs. The CDS envisages that 46.25% of the total cost of the priority

health measures equivalent to Rs 49 billion will be funded through international support.

The CDS costs the health insurance and voucher schemes for the province at Rs 16 billion

which represents 1.67% of the total Rs 960 billion CDS outlay over the next seven years

and are reflected separately under the priority measures for Social Protection.

The CDS states that the interventions related to MDG 6 are financed through the Federal

Government’s vertical programmes and, as such, have not been reflected in the CDS

costing. The CDS allows for Rs 21 billion for vertical programmes over the next seven

years. This cost does not reflect the additional burden of Rs 7 billion for the next seven

years which has arisen due to the recent decision by the Supreme Court to double the

salary of the LHWs.Thus in total the cost of the vertical programmes for the next seven

years would be Rs 28 billion.

The cost of the Polio Eradication Initiative (PEI) was not included in the CDS as the 18th

Amendment had not been promulgated at that time. Under the new scenario there is a lot

of uncertainty regarding the source of financing of the Polio Eradication Initiative. However

the cost of PEI is reflected in the Health Sector Strategy as it is one of the priority areas for

health interventions.

None of the costs reflected in the CDS take into account the impact of inflation over the

next seven years.

The 7th National Finance Commission award has been signed in December 2009. This

represents the agreement over the annual distribution of financial resources among the

provinces of Pakistan by the Federal Government. The new award comes into effect from



2010-11. In the first year under the new NFC award the provincial share of the divisible

pool would increase from 47.5% to 56%. For the remaining years under the award this

increases to 57.5%.

Under the new formula, Punjab will receive 51.74%, Sindh 24.55%, Khyber Pakhtunkhwa

14.62% and Balochistan 9.09% from the Federal government.54 Due to this increased %

allocation, the share of federal government allocations (including net hydel profits) are

expected to be around Rs 154 billion compared to Rs 83 billion in 2009-1055 an increase of

about 86%. This increased inflow from the federal government (including net hydel profits)

has resulted in a significant increase in allocations for the health sector though not in the

same proportion as noted above. The total provincial health budget (recurrent and

development) has increased from Rs.8.4 billion in 2009/10 to Rs. 12.5 billion in 2010/11 i.e.

an overall increase of 48%. The recurrent budget has increased from Rs.4 billion in

2009/10 to Rs.5.9 billion in 2010/11 (an increase of 47%) and the development budget has

increased from Rs. 4.3billion to Rs. 6.6 billion in 2010/11 (an increase of 53%).

Private vs. Public Expenditure The latest provincial health accounts were compiled as

part of the National Health Accounts – Pakistan 2005-06 by the Federal Bureau of

Statistics. According to the provincial health accounts, total health financing/expenditure in

Khyber Pakhtunkhwa, during the FY 2005/06 was Rs. 28,177 million. Of this total public

sector financing/expenditure was Rs.6,630 million (23.5% of the total). 56 Private

financing/expenditure, which mainly includes the private households’ OOP payments, was

Rs. 21,547 million (57% of the total).57 Therefore the ratio of public financing/expenditure to

private financing/expenditure was rather high at 1 to 3.25. Per capita expenditure on

health by the Provincial and District governments in 2008/0958 was Rs.471 (US$5.98). This

54 According to the CDS, the government of KHYBER PAKHTUNKHWA was receiving 83% of its

revenue from Federal sources.

55 Finance Department – White Paper 2010-11

56 Federal, Provincial,District Health Department and other ministries, departments, State Owned

Enterprises and foreign aid

57 Provincial Health Accounts included as part of the National health accounts – Pakistan 2005-06.

58 Using a projected population figure of 23,295,611 for 2009

Health Expenditure


rose to Rs.542 (US$6.88) with the addition of federal funds and to Rs. 581 (US$7.38) with

the addition of the development partner’s contributions.59 60

Health expenditure analysis from 2005/06 to 2009/10

District expenditures

Table 2 below shows the nominal recurrent expenditure which the districts spent on health

over the last five years.

Table 1 Nominal recurrent expenditure (Rs. millions) by the District Governments on

Health, funded by the Government of Khyber Pakhtunkhwa FY 2005/06 to

2009/10

Expenditure 2005-06 2006-07 2007-08 2008-09 2009-10 Total

Health Recurrent Expenditure 2,132 2,396 2,982 3,531 3,166 14,207

Total District Expenditure 23,849 28,205 31,173 35,257 40,247 158,731

Health Recurrent Expenditure as a

proportion of Total District Expenditure 8.9% 8.5% 9.6% 10% 7.9% 9.0%

Additional Expenditure under Peoples

Primary Health Initiative (PPHI) 0 0 37 70 142 249

Total Health Expenditure in District 2,132 2,396 3,019 3,601 3,308 14,456

Note: Reported expenditure was obtained from the District Appropriation Accounts prepared by the Accountant

General. PPHI is a federal program supporting 12 districts in Khyber Pakhtunkhwa

The District Health recurrent expenditure was expended on hospitals, RHCs, BHUs, Mother

and Child Health Centers, EPI, malaria, the TB Control Program and administration divided

59 The total expenditure on health in Pakistan in the National Health Accounts of 2005-6 was estimated

to be US$18 per capita, of which the public sector expenditure was US$ 4 per capita. This is far below

the figure of US$34 proposed by the Commission on Macroeconomics and Health to provide an

essential package of health services

60 Over the last 15 years, public health expenditures have increased by 50% in nominal terms, however

taking into account population increase and inflation, real expenditure as a percentage of GDP has

stagnated at 0.55 to 0.58%. The FY 09 total expenditure on the health sector through the PRSP

channel declined to Rs 26,819 million down from Rs. 61,127 million in FY08.



in to salary and non-salary items. For FY 2009-10 the expenditure on salary items was Rs

2,735 million and expenditure on non-salary items was Rs 431 million.

Provincial expenditures

Over the five years the total expenditure of the Khyber Pakhtunkhwa provincial government

for health increased in nominal terms from Rs. 3,357million to Rs.6,228 million (Table 3).

The increase in nominal non-development expenditure from 2005/06 to 2009/10 was from

Rs. 2,077million, to Rs.4,453 million during 2009/10. However the largest increase is under

the development component where the expenditure increased from Rs.1,280 million in

2005/06 to Rs.3,882 million in 2008/09 (an increase of 203%)61.

Table 2 Nominal Expenditure (Rs. millions) by the DoH, funded by the Government

of Khyber Pakhtunkhwa FY 2005/06 to 2009/10


Health recurrent expenditure 2,077 2,531 3,191 3,554 4,453 15,806

Health development expenditure 1,280 2,195 3,140 3,882 3,492 13,989

Total Health expenditure 3,357 4,726 6,331 7,436 7,945 29,795

Total Provincial Expenditure 90,917 94,632 109,857 139,338 138,823

Health Department expenditure as a

proportion of total expenditure of

Provincial Government

3.7% 5% 5.8% 5.3% 5.7%

Note: Reported expenditure was obtained from the Appropriation Accounts of Government of Khyber

Pakhtunkhwa (prepared by the Accountant General). 2009-10 expenditure up to end May 2010 only.

The Provincial DoH expenditures were expended on hospital services, drug control,

training and research institutions, university/colleges/institutions, drug testing and food

laboratories and administration and divided between salary and non-salary expenditure.

The salary expenditure comprises of the pay and allowances of officers and their staff. The

non-salary expenditure comprises of operating expenses, repairs and maintenance,

transfers and travelling allowances.

61 The increase in funds has primarily been invested in construction of new hospitals; improvement and

up gradation of health facilities and procurement of equipment & furniture etc for new and upgraded

health facilities

Health Expenditure


Table 3 Real adjusted Expenditure (Rs. millions) by the DoH, funded by the

Government of Khyber Pakhtunkhwa FY 2005/06 to 2009/10


Recurrent nominal 2,077 2,531 3,191 3,554 4,453 15,806

Recurrent real 2,077 2,331 2,690 2,570 2,295 11,963

Development nominal 1,280 2,195 3,140 3,882 3,492 13,989

Development real 1,280 2,021 2,647 2,807 1,800 10,555

Total provincial health expenditure

nominal 3,357 4,726 6,331 7,436 7,945 29,795

Total provincial health expenditure

real 3,357 4,352 5,337 5,377 4,095 22,518

CPI 7.92 7.77 12 20.77 11.49

Inflation 100 107.92 115.69 127.69 148.46

Note: Reported expenditure was obtained from the Appropriation Accounts of Government of Khyber

Pakhtunkhwa (prepared by the Accountant General). This expenditure does not include expenditure in

health at the District level.

As can be seen from the above table, due to the high rate of inflation in recent years the

purchasing power of the Rupee has eroded to nearly half of its purchasing power in FY

2009-10. Thus in real terms the government will have to double its outlay on health in

nominal terms in FY 2010-11 in order to keep pace with the rate of inflation and provide the

same level of health services it provided in 2009-10. As noted above, the overall health

outlay in nominal terms has increased by only 48%. This increase is insufficient to maintain

the level of services currently provided to the public and needs to be doubled in order to

keep pace with the rate of inflation.

Combined expenditures

The combined expenditure of district, provincial, federal, and development partners is

shown below in Table 5.



Table 4 Combined expenditure (Rs. millions) in health sector of Khyber

Pakhtunkhwa in 2007/08 and 2008/09

Expenditure 2007-08 2008-09 Total

District Government 3,019 3,601 6,620

Provincial Government 6,331 7,436 13,767

Federal Government 1,392 1,668 3,060

Development Partners 1,543 838 2,381

Total combined expenditure 12,285 13,543 25,828

Note: Reported expenditure was obtained from the Appropriation Accounts 2007-08 and 2008-09 of

Government of Pakistan and Khyber Pakhtunkhwa. Development partners expenditures obtained from

the Development Assistance Database. www.dadpak.org 62

The combined expenditure in the health sector increased from Rs.12,285 million in 2007/08

to Rs.13,543 million in 2008/09, an increase of Rs.1,1,258, or 10%. The increase in

expenditure was due to increased funding by the provincial government.

The federal government provided funds medicines and contraceptives through health

programmes, in particular, the NP FP&PHC and MNCH. Assistance was provided in-kind

for the EPI, hepatitis, TB and malaria, programmes. The Federal Government provided

funds for civil works in FY 2007/08 (Rs. 131.150 million), but not in 2008/09.

The Federal Government increased its overall funding to the provincial government from

Rs. 1,392 million in 2007/2008 to Rs. 1,668 million in 2008/2009, an increase of 20% .

62 Although the development partners and donors expenditures might have been higher, but only

expenditure reported on the official website has been used.

Health Expenditure


Allocation vs. expenditure

Figure 1 Provincial health allocation vs. expenditure FY 2005/06 -2009/10

Figure 2 District health allocation vs. expenditure FY 2005/06 -20009/10

0

1000

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2005-06 2006-07 2007-08 2008-09 2009-10

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2005-06 2006-07 2007-08 2008-09 2009-10

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Allocation

Expenditure



Variation in health expenditure between districts

There is a large variation in per capita expenditure between districts. This expenditure does

not take into account federal input via programmes such as the PPHI63, NP FP&PHC or for

Provincial inputs. The range is from Chitral with expenditure of Rs. 334 per person to

Peshawar at Rs. 77 (Figure 3).

Figure 3 District health expenditure per capita 2009/10

Notes Projected population figures from 1998 census, for 2009 District expenditure for 2009/10 from

Accountant

63 The PPHI districts are Chitral, Upper Dir, Malakand, Mardan, Charsadda, Peshawar, Nowshera,

Swabi, Haripur, Karak, Kohat.

0

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Funding implications


Part 5. Funding implications

Costing of priority health measures

Since the compilation of the CDS, the basis for the costing of the priority health measures have been further refined. These have

formed the basis of extensive discussions with the DoH to arrive at the costs required to implement the priority health measures

(Outcomes 1 to 5) as noted in the Table 6 below:

Table 5 Costing of Priority Health Measures (Rs. millions) in the health sector of Khyber Pakhtunkhwa FY 2010/11 to

2016/17 in Rs. Millions (R=recurrent, D=development)

Ou

tco

me 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2010-17

R D R D R D R D R D R D R D R D

1 2,424 6,282 2,690 21,220 3,013 22,315 3,375 25,505 3,780 29,108 4,233 33,279 4,741 38,054 24,256 175,764

2 9 4,573 10 5,626 5 6,025 5 6,748 6 7,558 7 8,465 7 9,480 48 48,474

3 2,794 1,650 2,900 1,691 2,761 2,082 3,092 632 3,463 708 3,879 793 4,344 493 23,233 8,050

4 205 175 230 196 257 220 288 246 323 275 361 308 405 345 2,068 1,766

5 172 140 448 146 564 163 492 28 629 31 529 0 592 0 3,426 508

Total 5,604 12,820 6,277 28,878 6,600 30,805 7,252 33,159 8,201 37,680 9,009 42,845 10,090 48,373 53,032 234,562

Note: Increase in overall cost over the CDS cost is due to the inflation factor which was not taken into account in the CDS costing.

Khyber Pakhtunkhwa health sector strategy draft


Assumptions: Outcome 1

1. Projected population millions in 2009: 23.3 million.

2. Population growth rate 2.8 % per annum.

3. Cost of MHSDP as per DoH: Rs. 340.

4. Rate of Inflation: 12 % per annum.

5. Population and MHSP Cost Projections:

Year Population MHSP Secondary HSP Tertiary HSP

2009 23.3 340 680 1020

2010 24.0 381 762 1142

2011 24.6 426 853 1279

2012 25.3 478 955 1433

2013 26.0 535 1070 1605

2014 26.7 599 1198 1798

2015 27.5 671 1342 2013

2016 28.3 752 1503 2255

2017 29.1 842 1684 2525

Utilisation % as per DoH

discussions 100% 10% 5%



6. Infrastructure Assumptions(CDS):

7. Workshop-bi annual, DOH office, 3 days and 60 participants. Staff and equipment requirements-Rs 2 million as per Qabil

Shah Khattak-Admin/Finance Officer-HSRU

8. Three person team for 150 days@ Rupees 40,000/day on average plus consultation workshop and logistics etc.

9. Two person BCC experts for 50 days@ Rupees 30,000/day on average plus field survey and logistics (Rs 2 million).

Dissemination of strategy through radio, focus groups and printed material (Rs 10 million).

10. Extrapolated recurrent and development expenditure for all 4 hospitals based on expenditure of PIPOS.

11. Two additional grade 16 officers plus training (Rs 100,000 pa) in all (19+125=144) hospitals up to THQ hospitals.

12. One person for 100 days @ Rs 40,000/day plus logistics etc.

13. As per Finance Dept white paper 2010-11 provincial revenue for 1% war on terror are expected to be Rs 15 billion.

Assumed 10% of this amount will be allocated to health interventions.


Rs. Millions BHU RHC

Total

Description Cost/Unit Units Sub-total Cost/Unit Units Sub-total

Phase 1 (year 1&2) 1 784 784 3 86 258 1,042

Phase 2 (year1&2) 5 784 3,920 10 86 860 4,780

New Construction (year 3-7) 30 75 2,250 150 25 3,750 6,000

Total

6,954

4,868 11,822



15. DHQ Hospitals (21) @ Rs 500 million each (CDS Back up docs) over 7 years. Per year Rs 1,500 million or 3 hospitals.


1. Rate of Inflation 12 % per annum.


3. In house quarterly meetings, 1 day activity but 3 sessions and 60 participants. Staff TA/DA and food requirements: Rs 1.75

million as per Qabil Shah Khattak-Admin/Finance Officer-HSRU.

4. In house quarterly meetings, 1 day activity. Staff TA/DA and food requirement: Rs 1 million.

5. Bi-Annual meetings, 1 day activity. Staff TA/DA and food requirement: Rs 1 million.

6. Includes Surveillance cost (Rs 17.1 million/month); Provincial Immunisation Day cost (Rs 110 million/day=Rs 37 million

operational cost+Rs 77 million vaccine cost).Three rounds YR1; six rounds YR2 & four rounds thereafter.



2. 500 Postgraduate practicing doctors@ Rs 20,000 stipend (http://the news.com.pk-Doctors support NWFP Body-16th June

2009).

3. One person for 90 days @ Rs 40,000 and logistics.



2. Due to lack of available details at this stage, the BESD-MTBF-2010-13 overall estimates were spread across the

component strategies along with any specific cost information obtained from CDS documents.





Funding of priority health measures

The funding sources for the priority health measures are the provincial governments own resources, its share of Federal

Government allocations, grant in aid, net profit from hydel and foreign grants and loans. Table 6 below shows the current and

projected levels of funding based on the Budget Estimates for Service Delivery-MTBF-2010-13 funding levels and the resulting

funding gap. As noted in the CDS, 46.25% of the total costs of the priority health measures are expected to be funded through

international support. Using this assumption Table 6 shows the level of funding which will be required by the government and

donors to sustain the priority health measures during the next seven years.



Table 6 Funding of Priority Health Measures (Rs. millions) in the health sector of Khyber Pakhtunkhwa FY 2010/11 to

2016/17 in Rs. millions

2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 2010-17

R D R D R D R D R D R D R D R D

Total Needs (A) 5,604 12,820 6,277 28,878 6,600 30,805 7,252 33,159 8,201 37,680 9,009 42,845 10,090 48,373 53,032 234,562

Funding Available

(B)

5,941 6,571 6,535 7,228 7,189 7,951 7,907 8,746 8,698 9,621 9,568 10,583 10,525 11,641 56,363 62,340

Funding Gap (A-

B)

6,249 21,650 22,854 24,413 28,060 32,263 36,732 172,221

Potential Funding

Government 3,359 11,637 12,284 13,122 15,082 17,341 19,744 92,569

Donors 2,890 10,013 10,570 11,291 12,978 14,922 16,989 79,652

Total 6,249 21,650 22,854 24,413 28,060 32,263 36,732 172,221

Note: R=recurrent, D=development

Implementation, monitoring and evaluation mechanisms


Part 6. Implementation, monitoring and

evaluation mechanisms

Implementation

To ensure that the strategy is implemented, detailed activity and project plans

will need to be designed and a PC-1/proposal prepared to secure the technical,

human and/or financial resources required.

Implementation will require the strong involvement of the Additional Secretary

(Development), and the HSRU. Given the current work commitments of these

senior members of the DoH, it is proposed that an Implementation Assistance

Team be located within the DoH, funded by a development partner for two

years. This would include two dedicated experts, a Health Sector Management

Specialist, a Financial Expert and an Office Manager. The role of the team will

be to support the DoH in developing project proposals, terms of references for

technical studies, surveys and other related activities. The team will develop

monthly, quarterly and annual progress reports on the implementation of the

strategy.

Monitoring and evaluation

The strategy needs to be monitored to ensure implementation. The government

of Khyber Pakhtunkhwa is currently developing a more comprehensive M&E

system linked to budget reform (MTBF). The M&E of the strategy will be

consistent with the M&E process of the CDS.

Performance indicators: To assess progress, the targets and indicators of the

CDS are core to the health sector strategy. There are also additional indicators

to be monitored that will provide information on the implementation of strategies

designed to impact on the five health outcomes (Part 3. Performance Indicators).

Annual report and review: An annual report reviewing implementation

progress will be provided to the Minister for Health, by the Secretary of Health.

This report will be prepared by the Provincial Information Management Unit.

This report will be used as a basis for an annual review. The annual review

process should be based on data collected through annual performance reports



from units and programmes within the Khyber Pakhtunkhwa health sector. It

should also rely on the health information and budget systems.

This review will ensure that additional services and major initiatives are included

in the strategy. It is expected that there will be changes as the 18th Amendment

is implemented. Advances in technologies and processes that will lead to

changes in some strategic initiatives such as the budget process (with the

implementation of the MTBF at the District level and implementation of the

DHIS) will provide further information for decision making and policy

development. The annual review will also enable insecurity and natural

disasters, and their consequences, to be taken into account.

Monitoring Committee: It is proposed that a Monitoring Committee to monitor

progress on the strategy be established, headed by the Secretary of Health with the

HSRU as the secretariat.

Proposed members include:

1. Secretary of Health (Chairman)

2. Additional Secretary (Development) Health

3. Additional Secretary (Establishment) Health

4. Director General Health Services

5. Chief Executive of an autonomous tertiary care/teaching hospital

6. Representative of KMU

7. Chief Planning Officer

8. Chief, HSRU (Secretary)

9. Director of PHSA

10. Chairman of the HRA

11. Director Monitoring and Evaluation Cell

12. A private sector medical professional

13. A delegate of a reputed health sector NGO

14. A consumer rights expert representing patients/consumers

15. A representative of professional associations of doctors, nurses and

paramedic staff.

This committee should meet quarterly and review progress against agreed

milestones. The proposed terms of reference are as follows:

a Oversee and steer the implementation of the Health Sector Strategy.

Implementation, monitoring and evaluation mechanisms


b Grant approval to work-plans, goals/outcomes, indicators, project

proposals and other documents submitted with regards to the

implementation of the strategy.

c Review the provisions of the strategy on annual basis to approve and ask

for modifications in light of changing scenarios (e.g. post 18th

amendment).

d Monitor progress on the implementation of the strategy.

Next steps

Key activities for finalising and implementing the health sector strategy

Activity Timeline Responsibility

Finalise draft of strategy 15 January 2011 Consultants/ HSRU

Approval of the strategy by DoH 30 January 2011 Secretary/ Minister

Health

Publish and disseminate the strategy 28 February 2011 HSRU

Finalise ToRs for the Health Sector

Strategy Monitoring Committee

(HSSMC) and notify committee

15 February 2011 Secretary of Health

Meeting of the HSSMC 20 February 2011 HSRU

Recruit technical assistance (TA) team

for support of the strategy

28 February 2011 Secretary of Health

Develop the Activity Plan with priorities

for year 1

30 March 2011 TA Team/ HSRU

Develop implementation/ project plans

for each strategy/ outcome

30 April 30 2011 TA Team/ HSRU

Provide inputs to preparation of ADP/

OBB in view of the strategy

May 2011 TA Team/ DoH

Review progress and revise strategy – if

needed

December 2011 HSSMC




Annex 1: Stakeholder consultation

Strategy development; the process

Strategy Development Team

In 2010, the Secretary of Health established a task force to formulate a strategy

for the health sector in Khyber Pakhtunkhwa. The strategy was to take into

account, the health status of the population, the current services being provided

and the availability of resources and then develop strategies for action. To

support the work of the task force, a consultancy team was contracted by the

Technical Resource Facility funded by UKAid (formerly DFID) of UK and AusAid

to work closely with the Health Sector Reform Unit (HSRU).

Major Activities

Initially the activities of the task force and the consultancy team focused on

defining the outcomes for the health sector and defining and costing outputs for

each outcome to support the DoH’s budget submission for the 2010/11 budget.

The situation analysis, identification of challenges, formulation of key objectives

and strategies were developed from; stakeholder consultations, key informant

interviews, and literature review.

Consultative workshops, held in April in Peshawar, were attended by

representatives of all major stakeholders from the public and non-government

sectors including; decision makers, service providers, civil society and academia

and from all levels; health centres, district and provincial. The purpose was to

identify challenges facing the health sector and to provide input into the

development of initiatives to achieve targets. Communication for Effective Social

Services Delivery (CESSD) and HSRU held two community consultations in

May. The first consultation was held in Peshawar for districts Peshawar, Mardan

and Swabi with 96 participants (36 women and 60 men) and the second one in

Kohat for districts Kohat, Abbottabad, Haripur, Nowshera with 130 participants

(50 women and 80 Men)

Strategy development workshop, a two day workshop to share the findings of

these workshops and to progress the development of the strategy was

Stakeholder consultation


organised in June with the senior managers of public sector and partner

organisations at the provincial and federal level.

Key informant interviews were conducted with managers within the DoH

including those managing public health programmes and hospitals.

Data was sourced from major surveys conducted or approved by government,

research from medical universities and the World Health Organisation.

Risk Matrix

P= probability, S = significance

Risk S Mitigation Strategies

The Health Sector Strategy will be

implemented in an environment of

economic hardships, realignment of

linkages between different levels of

government and uncertainties due to

security situation. There is a strong

possibility that the economic and

security situation constraints may lead

to disruptions in the Strategy

implementation.

H

H

It will be important for the government and

other partners to mitigate this risk

by building strong ownership and

buy-in of different levels of

government, private sector and

development partners through

enhanced awareness and

understanding of the important

elements of the strategy.

Strong support from a wide range of

external donors and development

partners would help meet this risk.

There are apprehensions that the conflict,

which is primarily taking place in

remote and difficult terrain, of the

province and adjoining areas of FATA

will prove to be protracted. At the

same time, the war in Afghanistan is

growing in intensity. Targeting

programs in conflict affected areas, as

the Strategy proposes, greatly

increases the exposure to risks.

Deterioration in security across the

entire country is also possible. In this

context, attracting foreign investment

H H Strong engagement of health department

with senior political, administrative

and LEAs to coordinate efforts in

health sector with security

situation.

Use of the PCNA as a means of conflict

analysis.

Increased involvement of the communities in planning and oversight of the health sector initiatives so that these are seen as community



will remain a challenge and the conflict

will continue to be a drain on the

resources and attention of the

Government and people of the

province.

owned and not as ‘outside’ interventions.

The large increase in spending by government

& other partners leads to blockages

and delays in Government service

delivery and increases the risks of

mismanagement due to weak

implementation capacity.

M M Realistic annual plans/PC-1s. Closer

coordination and synergies with

other partners, sectors and the

option of outsourcing of services

wherever possible.

Inadequate management capabilities and

information systems

H M Provision of adequate funding for

organisational development.

Initiate health department review on

priority basis.

Uncertainty around decentralisation/devolution

which could lead to districts having

decision making and planning

functions thus minimising provincial

government authority, where some

local governments are not willing to

adopt the strategy.

L L Annual planning process to take such

developments into consideration.

Ineffective targeting of the poor & vulnerable.

H L Effective link mechanisms to poverty data

bases ; use of self-selection in

design of package

Lack of effective mechanisms for assuring

good quality of services & regulations

H M Strengthened HRA and quality plan.

Determining Strategic Priorities

The criteria for developing the strategies under each health outcome were as

follows: Commented [TJL21]: Where are a-d?



a) Will the strategy contribute to addressing the health issues of the

population especially the poor and vulnerable (women and children)?

b) Does the strategy effectively address a major public health issue?

c) Is the strategy responding to community needs?

d) Does the strategy contribute towards strengthening of the health system?

e) Is the strategy in line with the policy documents, international

commitments and reform agenda of the government?

f) Is the strategy in accordance with the governments manifesto?

g) Is the strategy likely to attract support?

h) Is the strategy financially feasible and sustainable?

i) Can it be accomplished within the current DoH management capacity?

j) Are any additional resources available (material, human and financial)?

This set of criteria could be used by the DoH for identifying priorities in its regular

planning process.

List of consulted stakeholders

The following stakeholders were consulted in the development of this strategy.

There is a separate report for the district level community consultations.

1 Dr Ghulam Hazrat MO –Dir Upper

2 Ms Nasim Akhtar LHV –Dir Upper

3 Dr Zafar Ahmad GM-AKHSP

4 Dr Maqsood Ahmad EDO (H) Buner

5 Dr Shafeul Malik District Coordinator NP/EPI

6 Mian Irshad Admin Officer, EDO Shangla

7 Dr Saeeda Saeed Principal Public Health School Nishtarabad

8 Mr Hameed ur Rehaman DSM, PPHI , Malakand

9 Dr Aman ullah SMO Incharge THQ Hospital Matta (Swat)

10 Ms Abida LHS NP&PHC Charssada

11 Dr Nadeem Ahmad Project Director-IQHCS

12 Dr Shahzad Faisal DMS KTH



13 Dr Akhtar Said Coordinator (DEPRU) Swat.

14 Dr Nasreen Asghar WMO –CD Bhana Mari Kohat road Peshawar.

15 Dr Wakeel MS DHQ Temergara

16 Ahmad Shah JCS-DHQ Temergara

17 Dr Shaukat Ali Distt TB Officer Peshawar

18 Dr Rafiullah Distt Coordinator Swat

19 Dr Noorulmabood Deputy DHO Peshawar

20 Dr Jamshad Ahmad M.S Emergency Statalite Hospital Nahaqi

21 Mr Imran Ulllah Khan Drup Inspector Charssada

22 Dr Khurshid Ahmad Bice Pricipal SGTH Swat

23 Dr Saeed Ahmad RMO –RHC Shagram (Chitral)

24 Dr Lubna Tahir WMO-DHQ Taimargara

25 Dr Allah Yar DTO –Charssada

26 Dr Saeed Gul AD- (P-I) DGHS

27 Dr Hidayatullah EDO Health Dir Upper

28 Dr Obaid ur Rahman Coordinator –HSRU

29 Dr Azmat ullah Khan Coordinator –HSRU

30 Dr Tahir Nadeem Director M&E Cell

31 Mr. Jamal Afridi JSI/Paiman

32 Muhammad Ishfaq MIS Officer/ IQHCS

33 Dr SherQayyum EDO H Chitral

34 Dr Israrulllah Vice Principle –DHDC Chitral

35 Dr Shabina Raza Chief HSRU

36 Dr Shaheen Afridi Deputy Chief HSRU

37 Ms Akhtar Bano Lecturer/PGCN/KMU, Peshawar

38 Dr Ruhullah Jan Director Health –DGHS

39 Dr Qazi Afsar AD-EPI



40 Dr Shahid Younis Coordinator-HSRU

41 Dr Ambreen Qazi Health Officer –UNICEF

42 Dr Talat jabeen WMO-DHQ Taimargara

43 Dr M Saleem Khan Dy Program Manger RBM

44 Dr Adnan Taj DMS- LRH

45 Dr Tariq Saleem Marwat District Coordinator NP for FP & PHC Laki Marwath

46 Malik Rab Nawaz Social Worker Ustarzai Payan kohat

47 Abdul Hameed Coordinator HMIS EDO(H) Kohat

48 Dr Muhammad Sher

Khan D EDO (H) Kohat

49 Akhtar Jehan Assistant Director Nursing

50 Dr Khalid Iqbal Programme manager Roll back Malaria programme

51 Sabir Ali Chief Drug Inspector Health Dept

52 Dr Shakoor Rahman M/O Health Dept

53 Dr Nazish WMO DHQ Hango

54 Dr Samia Saeed WMO women and children hospital Kohat

55 Dr Abid Jamil Director Medical Education PGMI, Peshawar

56 Dr Umar Naseer MO RHC Distt Karak

57 Dr Siraj Muhammad Secretary Medical facility Peshawar

58 Dr Islamud din MO Lokki Health

59 Saadullah khan District Sanitary/Food Inspector EDO (H) Office Mardan

60 Dr Qiaser Ali PHC EDO(H) Office Mardan

61 Arbas Khan District Drug Inspector EDO(H) Office Mardan

62 Mahboob Ur Rehman District Planning Officer Hangu

63 Momin Khan Marwat EDO (Finance and Planning) Laki Marwat

64 Waqar Khan Monitoring Officer Khyber PakhtunkhwaK

65 Waqar Ahmad Monitoring Officer RMU Deptt Khyber PakhtunkhwaK



66 Dr M Aman Khan PICO HMC Peshawar

67 Dr Mokaish M/S MMC Mardan

68 Dr Hafiz ullah DMS Bannu

69 Kanwal Iqbal SFC CESSD Peshawar

70 Dr Amin ul haq DPC, LHW Program

71 Dr Syed Javed Husain Shiffa International Hospital Islamabad (former MNA,

Kurram Agency)

72 Dr Syed Arif Hussain Health Systems Specialist

73 Dr Imtiaz Ali Shah Coordinator HSRU

74 Ms. Shukria Syed CESSD Peshawar

75 Dr Mohtasim Billa

76 Aqeel Badshah Khattak Deputy Secretary of Health

77 Dr M. Javed khan Senior Advisor GTZ Peshawar

78 Dr Sardar Muhammad D-DHO Abbottabad

79 Dr Ahmed Faisal Health District Coordinator EPI Abbottabad

80 Dr Rafiullah Bangash DRCS/GRC Health Program manager Peshawar

81 Sher Muhammad Anesthesia teacher DHQ Swabi

82 Muhammad Irshad District Operation Assistant Mansehra

83 Dr Ali Ahmed Provisional Programme manager DHIS. DOH

84 Syed Muhammad Ilyias CEO Paraplegic Center Hayatabad Peshawar

85 Dr Siddique ur Rahman Project Manager(Save the Children) Batagram

86 Abdur Rashid EDO Social Welfare Department Mansehra

87 Shahzad Naeem Chief Executive Ayub Medical Institute Abbottabad

88 Dr Shahid Nisar Khalid District Specialist Surgery Swabi

89 Ms Shakila Begum Controller NEB, Peshawar

90 Dr Niaz Muhammad M/S KAITH Mansehra

91 Dr Saeed Ijaz Ali shah District Coordinator NP for FP & PHC Mansehra



92 Dr Mushtaq Ahmed Khan TA, SHSR FATA/GTZ

93 Dr Khalid Mashood Programme Officer GTZ Peshawar

94 Javed Ali Press Reporter Peshawar

95 Dr Ayub Khan EDO, Health Batagram

96 Dr Muhammad Azam

Khan Hepatitis Programme Peshawar

97 Pervez Akhtar Health / Economist Peshawar

98 Khuram National Programme Mansehra

99 Dr Raza Muhammad

Khan MTA Health System PRIDE

100 Akmal Minallah PFM Advisor Provincial Reform Programme Project

101 Ivan G. Somlai CESSD/CIDA

102 Dr Zia Ul hasnain DOH Peshawar

103 Mobashar malik UNFPA

104 Alexandra Pluschke GTZ

105 Rahim Zada CPO health Khyber PakhtunkhwaK

106 Saadiya Razzaq HSSPU

107 Dr Muhammad Sohail K.

Hashmi PMDC

108 Dr Usman Raza Peshawar Medical College

109 Dr Alamgir Khan Shinwari Director Administration DGHS Health Department

110 Prof Shad Muhammad Khyber Medical University

111 Dr Inam Ullah UNICEF

112 Dr Muhammad Rahman WHO

113 Dr Raza Zaidee DFID

114 Dr Akhtar Said Health Department

115 Dr Imran Khan Deputy Director (IQHCS)

116 Dr Amber Ali Chief Economist P&D Department Khyber



Pakhtunkhwa

117 Aziz Khan Khattak Additional Secretary of Health Department Khyber

Pakhtunkhwa

118 Dr Muhammad Saleem

Wazir Ayub Medical College Abbottabad

119 Dr Shahid Pervaiz DHO,HQ Punjab HD Rawalpindi

120 Dr Inam Ul Haq World Bank

121 Naseem Firdous Program Officer TRF

122 Imdad Ullah Khan TRF

Documents

Khyber Pakhtunkhwa Health Sector Strategy 2010 2017healthkp.gov.pk/public/uploads/downloads-42.pdf · BHU Basic Health Unit BISP Benazir Income Support Programme ... MO Medical Officer